NCC241561_FRO Submitted_20240522

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may initiate any land-disturbing activity on one or more acres as covered by the Wake
County 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 cARotiN,, 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 NORTH WAKE EYE CARE
2. Location of land-disturbing activity: Jurisdiction WAKE CO/ToR (Wake Co. or Municipality)
GRANITE FALLS BLVD/
Highway/Street ROGERS RD Latitude 35°55'25.7"N Longitude_ 78°28'02.5"W
3. Approximate date land-disturbing activity will commence: NOVEMBER 2023
4. Type of development (residential, commercial, industrial, institutional. etc.):COMMERCIAL
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 1.4
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name JUSTIN JACKSON E-mail Address [e-mail]
Telephone Cell# [phone] Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
SJM HOLDING COMPANY, LLC '919) 554-2440 [e-mail]
Name(s) Telephone Fax or E-mail address
303 MIDDLEHAM DRIVE -SAME-
Current Mailing Address Current Street Address
ROLESVILLE, NC 27571-9209 -SAME-
City State Zip City State Zip
8. Deed Book No. 015490 Page No. 00569 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):
SJM HOLDING COMPANY, LLC [e-mail]
Name E-mail Address
303 MIDDLEHAM DRIVE -SAME-
Current Mailing Address Current Street Address
ROLESVILLE, NC 27571-9209 -SAME-
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:
STEPHEN J ME-RKt rnet C - ( [e-mail]
Name of Registered Agent E-mail Address
303 MIDDLEHAM DRIVE -SAME-
Current Mailing Address Current Street Address
ROLESVILLE, NC 27571-9209 -SAME-
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.
STEPHEN J MERI�CE Y j 1 MANAGERSJM HOLDING COMPANY, LLC
Type or print name Title or Authority
ignature Date
I, Ro a1lC(C AVVe 1 , a Nota Public of the of \v,ir��`(� � Notary County U--
State of North Carolina, hereby certify that ¶ Icy y, y71A,cx t appeared
personally before me this day and being duly sworn acknowledgedthat the above form was executed by him.
Witness my hand and notarial seal,this' day of 0 , 20 2 3
SANDRA MCCONNELL
hgeagy Public
Wake Co.,North Carolina My commission expires )/IC& L( T2 4
My Commission Expires May.21,2024