NCC233816_FRO Submitted_20240103

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Nar„e Fuquay-Varina Southern Oaks Gravity Sewer Outfall - Phase
2. Location of land-disturbing activity: County Wake City or Township Fuquay-Varina
Wagstaff Rd.to Bowling Rd. ( g ) 35.566635 LOngltUde(decimal degrees) -78.809735
Highway/Street Latitude decimal de rees
3. Approximate date land-disturbing activity will commence: 1/2/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): municipal sewer
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas l: 9.1 3
6. Amount of fee enclosed $3,000.00 _ The Express Permitting application fee is a dual charge.
The normal fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express
Permitting supplemental fee is a fixed$2,000.00 (Example: 8.10-acre application fee is$2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Clark Maness E-mail Address [e-mail]
Phone: office# 919-469-3340 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Currin, Ronald J.
Name Phone: Office# Mobile#
117 Progress Drive 117 Progress Drive
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
10. Deed Book No. 18696 Page No. 216 Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s) of the owner(s)may be listed as the financially responsible party(ies).
Town of Fuquay-Varina [e-mail]
Company Name E-mail Address
134 N. Main Street 134 N. Main Street
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Phone: Office# 919-552-1401 Mobile#
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, 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
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General

Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
WithersRavenel [e-mail]
Engineering firm or other consultant E-mail Address
Clark Maness 919-469-3340 919-535-5213
Individual contact person (type or print) Phone: Office# Mobile#
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Adam Mitchell Town Manager
Type or pri nam Title or Authority
//2-0/7-4 2_
Sig a ure Date
I, ) e(es . till i j d€V , a Notary Public of the County of 1ikJ ol,i`1
State of North Carolina, hereby certify that kackvA 1V1 i4cihe I appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
4-4
Witness my hand and notarial seal, this o�0 day of Nov ry,10-2 r 20 23
+....0,,.,,lye,, Notary
1'10 /5/aSeal �';xs n My commission expires

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:
Town of Fuquay Varina 919-567-3919
Name Phone: Office# Mobile#
134 N. Main St. 134 N. Main St.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No.8123 Page No.241 Provide a copy of the most current deed.
Landowner 3 of Record:
Tate, Thomas R., Marilyn J.
Name Phone: Office# Mobile#
1501 S. Main St. 1501 S. Main St.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No.3081 Page No.208 Provide a copy of the most current deed.
Landowner 4 of Record:
Tate, Thomas R., Marilyn J.
Name Phone: Office# Mobile#
1501 S. Main St. 1501 S. Main St.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No.4351 Page No. 648 Provide a copy of the most current deed.
Landowner 5 of Record:
Tate, Thomas R., Marilyn J.
Name Phone: Office# Mobile#
1501 S. Main St. 1501 S. Main St.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Page No. 38
Deed Book No.4427 Provide a copy of the most current deed.

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 6 of Record:
CANNADAY, BONNIE A. E., JEANNE F.
Name Phone: Office# Mobile#
PO Box 278 1436 S. Main St.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No. 13662 Page No.2290 Provide a copy of the most current deed.
Landowner 7 of Record.
Jones, Douglas Lane
Name Phone: Office# Mobile#
529 Sunset Dr. 1825 Bowling Rd.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No. 6624 Page No.632 Provide a copy of the most current deed.
Landowner 8 of Record:
Hendrick, Susan
Name Phone: Office# Mobile#
PO Box 531 1728 Bowling Rd.
Current Mailing Address Current Street Address
Buies Creek NC 27506 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No.5963 Page No. 128 Provide a copy of the most current deed.
Landowner 9 of Record:
Laurel Lake Club
Name Phone: Office# Mobile#
6344 Whitted Rd. 6344 Whitted Rd.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No.$117 Page No 1574
. Provide a copy of the most current deed.

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 10 of Record:
Town of Fuquay-Varina 919-567-3919
Name Phone: Office# Mobile#
134 N. Main St. 134 N. Main St.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No.5441 Page No. 388 Provide a copy of the most current deed.
Landowner 11 of Record:
Marchioni, Barbara K., Victor F.
Name Phone: Office# Mobile#
1519 S. Main St. 1519 S. Main St.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No. 11684 Page No.2127 Provide a copy of the most current deed.
Landowner 12 of Record.
Main Street Catering
Name Phone: Office# Mobile#
1613 S. Main St. 1613 S. Main St.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No. 9607 Page No.91 Provide a copy of the most current deed.
Landowner 13 of Record:
Bradley,Eugene L.Co-Trustee;Englad,Foy G.Co-Trustee
Name Phone: Office# Mobile#
1930 S. Main St. 1930 S. Main St.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No. 993 Page No. 732 Provide a copy of the most current deed.

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 14 of Record:
Gunter, Barbara P.
Name Phone: Office# Mobile#
410 Geranium Ct. 1911 S. Main St.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No. 12-E Page No.3205 Provide a copy of the most current deed.
Landowner 15 of Record:
Gentry, Craig W., Valeska C.
Name Phone: Office# Mobile#
1629 S. Main St. 1629 S. Main St.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No. 14446 Page No.218 Provide a copy of the most current deed.
Landowner 16 of Record:
Stancil, Fred L., Kathy H.
Name Phone: Office# Mobile#
446 Stancil Rd. 446 Stancil Rd.
Current Mailing Address Current Street Address
Angier NC 27501 Angier NC 27501
City State Zip City State Zip
Deed Book No. 1129 Page No. 90 Provide a copy of the most current deed.
Landowner 17 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.