NCC241500_FRO Submitted_20240531

IRVA
V:-.;. WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
illi `'*y~ SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
WAKE County Unified Development Ordinance before this form and an acceptable erosion and
rr
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
NORTH CAROLINA 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 Zebulon Animal Hospital
2. Location of land-disturbing activity: Jurisdiction Town of Zebulon (Wake Co. or Municipality)
Highway/Street 1620 N.Arendell Ave. Latitude 35.842 Longitude-78.327
3. Approximate date land-disturbing activity will commence: 4/19/2024
4. Type of development(residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 1.84
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brian Wood E-mail Address brianwood(thevetsoets.com
Telephone [phone] Cell# N/A Fax# N A
7. Landowner(s)of Record (attach accompanied page to list additional owners):
ZAH Realty. LLQ 252-237-1375 brianwoodt thevetsdn
Name(s) Telephone Fax or E-mail address
235 Nash St. E. _ Same
Current Mailing Address Current Street Address
Wislon NC 27893 Same _
City State Zip City State Zip
8. Deed Book No.019476 Page No.01096 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):
ZAH Realty, LLQ brianwoodt&thevetspets.com
Name E-mail Address
325 Nash St. E. Same
Current Mailing Address Current Street Address
Wilson _ NC 27893 Same
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:
6ry /414-- �L"l�15 e-Tiff�L efr�• �Ol�!
Name E-mail Address
GO cc.49 47 0 Sr �, e
Current Mailing Address Current Street Address
/t/C. 27d0/r r jq-/f
City State Zip City State Zip
Telephone,..25".2—,Z,FO-'/ , / 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:
Steven J.Thomas steventhomastthevetsoets.com
Name of Registered Agent E-mail Address
325 Nash St.E. Same
Current Mailing Address Current Street Address
Wilson NC 27893 Same
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.
Brian Wood Director of Facilities
Type or print name Title or Authority
Signature Date
I, #4fr f4i//'2i4a , a Notary Public of the County of lc-,56W
State of North Carolina, hereby certify that ./L./.i•-/ UD 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 /y' day of Als22.41/ ,
Steven Lee Oliverio
SeaINOTARY PUBLIC
Wilson County,NC My commission expires /J--4:9 1D.Z.$
My Commission Expires//-/E2'2