NCC233465_FRO Submitted_20231122

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
E7NoCounty person mayed initiateDevelopment any land-disturbingOrdinance activity before onthis oneform or moreand acresan acceptable as covered byerosion the Wake and
U ni fiTY sedimentation control plan have been completed and approved by Wake County Department of
Environmental Services, Water Quality Division. (Please type or print and, if the question is not
I applicable, place N/A in the blank.)
Part A. Wallbrook Roadway Improvements -Wallbrook Drive & Virginia Water Drive (CID 23-01)
1. Project Name Publix at Wallbrook (SDP 23-05)
2. Location of land-disturbing activity: Jurisdiction Rolesville (Wake Co. or Municipality)
Highway/Street S. Main St./US 401 and Latitude 35.90889 Longitude - 78.47694
Virginia Water Drive
3. Approximate date land-disturbing activity will commence: October 2023
4. Type of development(residential, commercial, industrial, institutional, etc.): commercial & public roadways
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 20.08 acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Michael Isaac, P.E. E-mail Address misaac(@.csere.com
Telephone [phone] Cell# 919-610-7875 Fax# N/A
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Wallbrook Landco, LLC 704-621-6430 N/A
Name(s) Telephone Fax or E-mail address
3 Keel St. Suite 2 3 Keel St. Suite 2
Current Mailing Address Current Street Address
Wrightsville Beach, NC 28480-1709 Wrightsville Beach, NC 28480-1709
City State Zip City State Zip
8. Deed Book No. 018103 Page No. 01563 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 awilliamsi csere.com
Name E-mail Address
3 Keel St. Suite 2, 3 Keel St. Suite 2,
Current Mailing Address Current Street Address
Wrightsville Beach, NC 28480-1709 Wrightsville Beach, NC 28480-1709
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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:
Chris Taft [e-mail]
Name E-mail Address
2022 Progress Court Suite 100-110 2022 Progress Court Suite 100-110
Current Mailing Address Current Street Address
Raleigh NC 27608 Raleigh NC 27608
City State Zip City State Zip
Telephone [phone] 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:
J. Austin Williams [e-mail]
Name of Registered Agent E-mail Address
3 Keel St. Suite 2, 3 Keel St. Suite 2,
Current Mailing Address Current Street Address
Wrightsville Beach, NC 28480-1709 Wrightsville Beach, NC 28480-1709
City State Zip City State Zip
Telephone [phone] Fax Number N/A
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
ignature Date
I, 70kUG.r.r.r ury , a Notary Public of the County of A-r /7414t
State of North Carolina, hereby certify that -- . -4,-e0- c.'i i'm,,,,, , 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 g S day of 6-3-ef"t0.Hbrk- , 20 �3
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