NCC232079_FRO Submitted_20230710

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKE No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
n Det Ordinance be icbo
COUNTY sedimentationCountyU ified control planvelopmen have beenr completedefor and th s approvedform byand an Wakeac Countyepta le Departmenter sion ofand
NOIWI CAROUNA 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 Meadow at Jones Daity Phl -Lots 12-2I,41-52,73-80
2. Location of land-disturbing activity: Jurisdiction Rolesville (Wake Co. or Municipality)
Highway/Street Averette Road Latitude 35.954922 Longitude -78.460716
3. Approximate date land-disturbing activity will commence: Summer 2023
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 5.35 ac
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Teri Trefftzs E-mail Address [e-mail]
Telephone Cell# 919-256-5478 Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
The Drees Home Company
Name(s) Telephone Fax or E-mail address
8521 Six Forks Road,Suite 500
Current Mailing Address Current Street Address
Raleigh NC 27615
City State Zip City State Zip
8. Deed Book No. 019354 Page No. 01295-01299 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):
The Drees Home Company [e-mail]
Name E-mail Address
8521 Six Forks Road,Suite 500
Current Mailing Address Current Street Address
Raleigh NC 27615
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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(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:
Jerry Dean [e-mail]
Name of Registered Agent E-mail Address
21 1 Grandview Drive,Suite 140
Current Mailing Address Current Street Address
Ft. Mitchell KY 41017
City State Zip City State Zip
Telephone [phone] 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.
Jerry Dean Division President
Type or print name Title or Authority
X o - S o93
Signature Date
I,The roS a + 1 TI ' 4 Z--S , a Notary Public of the County of
State of North Carolina, hereby certify that 9( L 0-e appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
f�
Witness my hand and notarial seal, this day of ,_20
Notary
Seal fuyN 1_ k4 O h ti
My commission expires !� o'`
THERESA A. TREFFTZS
Notary Public
• Wake County,North Carolina
My Commission Expires
March 6,2024

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Preserve at Jones Dairy, LLC
Name Phone: Office# Mobile#
10534 Arnold Palmer Dr
Current Mailing Address Current Street Address
Raleigh, NC 27617
City State Zip City State Zip
Deed Book No.018255 Page No. 01 872 Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Lot Number PIN Address
12 1850831131 200 Murray Grey Ln
13 1850831046 204 Murray Grey Ln
14 1850831041 208 Murray Grey Ln
15 1850821758 224 Murray Grey Ln
16 1850821752 228 Murray Grey Ln
17 1850821676 232 Murray Grey Ln
18 1850821660 101 Whey Ct
19 1850821573 100 Whey Ct
20 1850822572 104 Whey Ct
21 1850823553 108 Whey Ct
41 1850924540 344 Murray Grey Ln
42 1850924499 348 Murray Grey Ln
43 1850925449 352 Murray Grey Ln
44 1850925499 356 Murray Grey Ln
45 1850926449 360 Murray Grey Ln
46 1850926499 364 Murray Grey Ln
47 1850927449 368 Murray Grey Ln
48 1850926646 361 Murray Grey Ln
49 1850925696 357 Murray Grey Ln
50 1850925646 353 Murray Grey Ln
51 1850924697 349 Murray Grey Ln
52 1850924647 345 Murray Grey Ln
73 1850924719 540 Marthas View Way
74 1850924769 544 Marthas View Way
75 1850925718 548 Marthas View Way
76 1850925778 552 Marthas View Way
77 1850926729 556 Marthas View Way
78 1850925905 549 Marthas View Way
79 1850924956 545 Marthas View Way
80 1850924906 541 Marthas View Way