NCC242796_FRO Submitted_20240912

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 Unifiedntationcontrol Developmentplanhave Ordbe c be acbo
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and this approvedform bynd an Wake
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NORM(,A RI>I 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 Lake Glad Rd Watermain Construction Plans
2. Location of land-disturbing activity: Jurisdiction Town of Wendell (Wake Co. or Municipality)
Highway/Street Lake Glad Rd Latitude 35.76318 Longitude -78.37999
3. Approximate date land-disturbing activity will commence: August 1,2024
4. Type of development(residential, commercial, industrial, institutional, etc.): Utility Replacement
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 1.00 Ac.
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Sean Johnson E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
HDP Lake Glad LLC
Name(s) Telephone Fax or E-mail address
2810 Coliseum Centre Drive,Suite 120 2810 Coliseum Centre Drive,Suite 120
Current Mailing Address Current Street Address
Charlotte, NC 28217 Charlotte, NC 28217
City State Zip City State Zip
8. Deed Book No. 019587 Page No. 02543 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):
HDP Lake Glad LLC [e-mail]
Name E-mail Address
2810 Coliseum Centre Drive,Suite 120 2810 Coliseum Centre Drive,Suite 120
Current Mailing Address Current Street Address
Charlotte,NC 28217 Charlotte, NC 28217
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:
Sean Johnson [e-mail]
Name E-mail Address
2151 Energy Drive 2151 Energy Drive
Current Mailing Address Current Street Address
Apex, NC 27502 Apex, NC 27502
City State Zip City State Zip
Telephone [phone] 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:
Cogency Global, Inc.
Name of Registered Agent E-mail Address
2810 Coliseum Centre Drive, Suite 120 2810 Coliseum Centre Drive, Suite 120
Current Mailing Address Current Street Address
Charlotte, NC 28217 Charlotte, NC 28217
City State Zip City State Zip
Telephone 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.
Sean Johnson Authorized Agent
Type or rint name Title or Authority
Signature Date
ilt-%."- g/ 1 /2ti
I, JOI1A Ok " 5 , a Notary Public of the County of J0'14404
State of North Carolina, hereby certify that Sea t1 J0114504 appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
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Witness my,a sio d notarial seal, this � day of 4t4itijf , 20 D(�',`',�vk .. 8o/s y. I
Notary
Seal
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