NCC231872_FRO Submitted_20230621

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
County Dd be iao
COUNTY sedimentationUnified control planevelopment haveOr been completed inanceefor
and th s approvedform byand Wan ake Countyaccept ble Department sion ofand
NORTH GAROL[MA 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 WAKE CHRISTIAN ACADEMY PARKING LOT EXPANSION-PHASE II
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street 5500 Wake Academy Dr. Latitude 35.705015 Longitude -78.670652
3. Approximate date land-disturbing activity will commence: SPRING/SUMMER 2023
4. Type of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 2.7 AC.
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Mike Woods E-mail Address mikewoodsPwakechristianacademy.com
Telephone_(919)334-0974 Cell# N/A Fax# N/A
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Wake Christian Academy Inc. [phone] N/A
Name(s) Telephone Fax or E-mail address
5500 Wake Academy Drive 5500 Wake Academy Drive
Current Mailing Address Current Street Address
Raleigh NC 27603 Raleigh NC 27603
City State Zip City State Zip
8. Deed Book No. 17429 Page No.481 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):
Mike Woods mikewoodsna.wakechristianacademy.com
Name E-mail Address
5500 Wake Academy Drive _ 5500 Wake Academy Drive
Current Mailing Address Current Street Address
Raleigh NC 27603 Raleigh NC 27603
City State Zip City State Zip
Telephone [phone] 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:
Name of Registered Agent E-mail Address
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.
Mike Woods Head of School
Type or print name 44 Title or Authority
3 / aLt I a.a a,3
Signature
Date
I. yr OYi (/{(\,t--1l \ , a Notary Public of the County of
State of North Carolina, hereby certify that A/V-6 VV O 06t, 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 lit day of WtVLA - . 20�3
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