NCC241602_FRO Submitted_20240528

WPM 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
NO , , t,,IN:� 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 Culver's Wendell
2. Location of land-disturbing activity: Jurisdiction Wendell (Wake Co. or Municipality)
Highway/Street Taylor Road Latitude 35.77667 N Longitude 78.43337 W
3. Approximate date land-disturbing activity will commence: March 1st, 2024
4. Type of development(residential, commercial, industrial, institutional, etc.): Commerical
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 1.95 AC
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Erik Neudecker E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Nash Wendell Falls, LLC
Name(s) Telephone Fax or E-mail address
STE 250, 13777 Ballantyne Corporate PL STE 250, 13777 Ballantyne Corporate PL
Current Mailing Address Current Street Address
Charlotte, NC 28277 Charlotte, NC 28277
City State Zip City State Zip
8. Deed Book No. 015478 Page No, 01623 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):
JELB3, LLC [e-mail]
Name E-mail Address
7512 Dover Hills Drive 7512 Dover Hills Drive
Current Mailing Address Current Street Address
Wake Forest, NC 27587 Wake Forest, NC 27587
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:
Erik Neudecker [e-mail]
Name of Registered Agent E-mail Address
7512 Dover Hill Drive 7512 Dover Hill Drive
Current Mailing Address Current Street Address
Wake Forest NC 27587 Wake Forest NC 27587
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 gpshould there bbe0 any change in the information provided herein.
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Signature Date
I, t�ox.1. A. r-.0 i.X�.Wa`1..� , a Notary Public of the County of �-
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State of North Carolina, hereby certify that 3t-\ . �vrU O Ut;c--� appeared
personally before me this day and being duly sworn acknowledged that' he above form was executed by him.
rs Witness my hand and notarial seal, this 1,, day of � 'r\ , , 20 9-�
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