NCC233314_FRO Submitted_20231107

11:WI 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
WAKECounty 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 cnaOi.NA 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 Wallbrook Offsite Utility Improvements
2. Location of land-disturbing activity: Jurisdiction Rolesville (Wake Co. or Municipality)
Highway/Street Virginia Water Drive Latitude 35 54'26.29" N Longitude 78 28'15.90"W
3. Approximate date land-disturbing activity will commence: April 2023
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential and commercial
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 2 acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brian Oschwald, PE E-mail Address [e-mail]
Telephone [phone] Cell # n/a Fax# n/a
7. Landowner(s)of Record (attach accompanied page to list additional owners):
n/a - Existing City of Raleigh Permanent Utility Easement and Town Right-of-Way
Name(s) Telephone Fax or E-mail address
Current Mailing Address Current Street Address
City State Zip City State Zip
8. Deed Book No. Page No. 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):
Wallbrook Landco, LLC (Michael Isaac, PE) [e-mail]
Name E-mail Address
801 East Blvd
Current Mailing Address Current Street Address
Charlotte NC 28203
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:
Brian Oschwald, PE [e-mail]
Name E-mail Address
2703 Jones Franklin Rd, Suite 201
Current Mailing Address Current Street Address
Cary NC 27518
City State Zip City State Zip
919-481-4342
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:
Wallbrook Landco, LLC same as above
Name of Registered Agent E-mail Address
same as above
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.
J. Austin Williams Manager
Type or print name Title or Authority
Signature Date
I, ict c01') AnAe - , a Notary Public offf the County of No,-t (k,-A.-9ci
State of North Carolina, hereby certify that J. /L s t;4 \✓: I t c. s 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 z«i day of n•7 se CI y , 20 15
JACOB ANDERSON
Notary Public •
'
3„ %' North Carolina Notary
New Hanover County
My commission expires � ' T 1 I, t 0 a,7