NCC241897_FRO Submitted_20240702

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 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 Name Buck Jones Road Area Water Line Replacements
2. Location of land-disturbing activity: CountyWake City or Township Raleigh
Norman Place 35.77372 -78.73129
Highway/Street Latitude(decimal degrees) LongitUde(decimal degrees)
3. Approximate date land-disturbing activity will commence: October 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Water Main Replacement
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 6.30
6. Amount of fee enclosed: $700.00 . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is$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 Chris Windley E-mail Address [e-mail]
Phone: Office# 919.890.3879 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Raleigh and others (see list) 919.996.3494 N/A
Name Phone: Office# Mobile#
PO Box 590 222 West Hargett Street
Current Mailing Address Current Street Address
Raleigh NC 27602 Raleigh NC 27601
City State Zip City State Zip
N/A(Raleigh right-of-way) N/A(Raleigh right-of-way)
10. Deed Book No. Page No. _ 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).
City of Raleigh - William Wheeler [e-mail]
Company Name E-mail Address
P.O. Box 590 222 West Hargett Street
Current Mailing Address Current Street Address
Raleigh NC 27602 Raleigh NC 27601
City State Zip City State Zip
Phone: Office# 919.996.4582 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:
N/A
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:
N/A
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
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.
William Whee r, PE Director, Raleigh Water
Type-a( rint nam Title or Authorit
1
Signature Date
I, S4ra.`t. , a Notary Public of the County of fDLi ,57'ba1
State of North Carolina, hereby certify that 49' // 'ant_ 4/%ee/er appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this // day of J J7 , 20 a3
eisej�oG����
Via•-cz� h/�ses�6��
.'ACT q R y Notary
p My commission expires 7/7 9/Q S'
C/B L\C
: nn,, �"'�

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:
Angela R Scala
Name Phone: Office# Mobile#
5352 Barclay Drive 5352 Barclay Drive
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.016894 Page No. 01738 Provide a copy of the most current deed.
Landowner 3 of Record:
Ahmed Nadir Aitboulahri
Name Phone: Office# Mobile#
5348 Barclay Drive 5348 Barclay Drive
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.012015 Page No. 02676 Provide a copy of the most current deed.
Landowner 4 of Record:
Julie A Lewis
Name Phone: Office# Mobile#
5351 Barclay Drive 5351 Barclay Drive
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.019226 Page No. 01278 Provide a copy of the most current deed.
Landowner 5 of Record:
Simon George
Name Phone: Office# Mobile#
5344 Barclay Drive 5344 Barclay Drive
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.017991 Page No. 02386 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:
Natasha G Gainer
Name Phone: Office# Mobile#
5340 Barclay Drive 5340 Barclay Drive
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.015530 Page No. 01 055 Provide a copy of the most current deed.
Landowner 7 of Record:
Sarah Peeples Wilson
Name Phone: Office# Mobile#
5336 Barclay Drive 5336 Barclay Drive
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.010259 Page No.00275 Provide a copy of the most current deed.
Landowner 8 of Record:
Howard W. Snotherly
Name Phone: Office# Mobile#
5328 Barclay Drive 5328 Barclay Drive
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.004938 Page No.00200 Provide a copy of the most current deed.
Landowner 9 of Record:
Dolores German Roblero
Name Phone: Office# Mobile#
5341 Barclay Drive 5341 Barclay Drive
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.015434 Page No. 01082 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:
Charles R. Smith
Name Phone: Office# Mobile#
5324 Barclay Drive 5324 Barclay Drive
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.011538 Page No.02053 Provide a copy of the most current deed.
Landowner 11 of Record:
Simone Erica Kublin
Name Phone: Office# Mobile#
5308 Barclay Drive 5308 Barclay Drive
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.017139 Page No.00566 Provide a copy of the most current deed.
Landowner 12 of Record:
Barbara Jo Cochran
Name Phone: Office# Mobile#
5309 Barclay Drive 5309 Barclay Drive
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.012985 Page No.02006 Provide a copy of the most current deed.
Landowner 13 of Record:
Bruce H Corregan
Name Phone: Office# Mobile#
5313 Barclay Drive 5313 Barclay Drive
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.008325 Page No.01288 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:
Szymon Kordas
Name Phone: Office# Mobile#
5317 Barclay Drive 5317 Barclay Drive
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.017402 Page No.00485 Provide a copy of the most current deed.
Landowner 15 of Record:
Rebekah R. Beeker
Name Phone: Office# Mobile#
5321 Barclay Drive 5321 Barclay Drive
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.004243 Page No.00652 Provide a copy of the most current deed.
Landowner 16 of Record:
Laura Ivey Vance
Name Phone: Office# Mobile#
5304 Barclay Drive 5304 Barclay Drive
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.016147 Page No. 00922 Provide a copy of the most current deed.
Landowner 17 of Record:
Joseph W. Burton
Name Phone: Office# Mobile#
633 S Lakeside Drive 633 S Lakeside Drive
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.002423 Page No.00452 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 18 of Record:
Donald W. Eaddy
Name Phone: Office# Mobile#
648 S Lakeside Drive 648 S Lakeside Drive
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.001882 Page No. 00261 Provide a copy of the most current deed.
Landowner 19 of Record:
Jeffrey A. Zimmer
Name Phone: Office# Mobile#
637 S Lakeside Drive 637 S Lakeside Drive
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.017498 Page No. 00640 Provide a copy of the most current deed.
Landowner 20 of Record:
Oliver L Harrell
Name Phone: Office# Mobile#
5101 Stockton Drive 5101 Stockton Drive
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.001598 Page No.00103 Provide a copy of the most current deed.
Landowner 21 of Record:
Carrie P McKeown
Name Phone: Office# Mobile#
5300 Norman Place 5300 Norman Place
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.017984 Page No. 02733 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 22 of Record:
Lindsey Barbee McGowen
Name Phone: Office# Mobile#
5205 Norman Place 5205 Norman Place
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.016134 Page No.01 1 12 Provide a copy of the most current deed.
Landowner 23 of Record:
Leroy A. Laske
Name Phone: Office# Mobile#
5148 Norman Place 5148 Norman Place
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.010401 Page No.00498 Provide a copy of the most current deed.
Landowner 24 of Record:
Anna Johnston Murphy
Name Phone: Office# Mobile#
5128 Norman Place 5128 Norman Place
Current Mailing Address Current Street Address
Raleigh, NC 27606 Raleigh, NC 27606
City State Zip City State Zip
Deed Book No.018350 Page No.00779 Provide a copy of the most current deed.
Landowner 25 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.