NCC243129_FRO Submitted_20241010

"WI WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKE No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
y De be abo
COUNTY sedimentationCountUnified control planvelopment haveOrdinance been completedefor and this approvedform byand an Wake Countyaccept le Departmenter sion ofand
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 The Meadows at Hollybrook- Phase V
2. Location of land-disturbing activity: Jurisdiction Town of Wendell (Wake Co. or Municipality)
Highway/Street 600 Jasmine Street Latitude 35.764086 N Longitude -78.357693 W
3. Approximate date land-disturbing activity will commence: 10/2024
4. Type of development(residential, commercial, industrial, institutional, etc.) residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas) 11.0
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name David DeYoung E-mail Address [e-mail]
TelephoneN/A Cell# [phone] Fax# N/A
7. Landowner(s) of Record (attach accompanied page to list additional owners)
Smith-Edwards, LLC N/A [e-mail]
Name(s) Telephone Fax or E-mail address
2102 Pritchard Road 2102 Pritchard Road
Current Mailing Address Current Street Address
Clayton, NC 27527 Clayton. NC 27527
City State Zip City State Zip
8 Deed Book No. 013847 Page No.01368 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):
Smith-Edwards, LLC N/A
Name E-mail Address
2102 Pritchard Road 2102 Pritchard Road
Current Mailing Address Current Street Address
Clayton, NC 27527 Clayton, NC 27527
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:
David DeYoung [e-mail]
Name E-mail Address
985 Windy Road 985 Windy Road
Current Mailing Address Current Street Address
Apex NC 27502 Apex NC 27502
City State Zip City State Zip
Telephone[phone] Fax Number N/A
(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:
Randy L. Edwards N/A
Name of Registered Agent E-mail Address
2643 A Wendell Rd 2643 A Wendell Rd
Current Mailing Address Current Street Address
Wendell NC 27591 Wendell NC 27591
City State Zip City State Zip
Telephone [phone] Fax NumberN/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.
Fred J. Smith, Jr. Manager
: uretT
TitleorAuthority
Date
I. Trct j-• f-fWe fg,wi a Notary Public of the County of JaA,4
State of North Carolina, hereby certify that F;YAI 'j iin.►0.K1 Jr. 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 /clis day ofusi 202q
AVii."-/..7 ----
Brian K Strickland ` Notary
Seal NOTARY PUBLIC
Johnston County
North Carolina My commission expires ei��6
My Commission Expires August 1,2026