NCC231002_FRO Submitted_20230414

CWI WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
WAKE
County Unified Development Ordinance before this form and an acceptable erosion and
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
NORTH C..1ROI INA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
1. Project Name YMCA Camp Kanata Drainage Improvements
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Camp Kanata Rd Latitude 36.001104 Longitude -78.565276
3. Approximate date land-disturbing activity will commence: February 2023
4. Type of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 3.0 Acs.
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Mike Askew E-mail Address [e-mail]
Telephone [phone] Cell# 252-671-6117 Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Durham YMCA Camp Kanata
Name(s) Telephone Fax or E-mail address
13524 Camp Kanata Rd 13524 Camp Kanata Rd
Current Mailing Address Current Street Address
Wake Forest, NC 27587-8078 Wake Forest, NC 27587-8078
City State Zip City State Zip
8. Deed Book No. 1249 Page No. 203 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet. Include requested information):
YMCA of the Triangle Area
Name E-mail Address
801 Corporate Center Drive
Current Mailing Address Current Street Address
Raleigh, NC a7(d7)
City State Zip City State Zip
Telephone Fax Number

2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
Wake County to receive any notice, process, pleading in any action or legal proceeding arising out of any
matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land
Disturbance Permit:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
SR`cE HA'', 1pc.H He Lt' ic-A-17-1,1Ailiflt. %Ali
Name of Registered Agent E-mail Address
LGt-Ii--1 ,l c IX
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
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S re Date
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Dt \r1 S kr Chi? , a Notary Public�� of the County of W�^1`N�.
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State of (North Carolina, hereby certify that p(\Oft l�-. r\QQA appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this Lp day of fr04- t 1 , 20 c2.3
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O� AR), Notary
My commission expires I/Co/
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