NCC221127_FRO Submitted_20220322

O-W 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
County 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
NORTH CAFM(ANA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
1. Project Name Neuse River Veterinary Hospital
2. Location of land -disturbing activity: Jurisdiction Town of Wendell (Wake Co. or Municipality)
Wendell Falls Parkway
HighwayfStreet Sid-2504 Latitude 35-46-11 N Longitude 78-25-03 W
3
4
5
6
7
Approximate date land -disturbing activity will commence: December 2021
Type of development (residential, commercial, industrial, institutional, etc.). -
Total acreage disturbed or uncovered (including off -site utilities
areas): 1.8
Commercial
and borrow/waste
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Amos Greene E-mail Address [e-mail]
Telephone [phone] Cell # [phone] Fax #
Landowner(s) of Record (attach accompanied page to list additional owners): 1) Parcel 1; 2) Parcel 2
1) Connie L. Jones; 2) CSSNC LLC (Connie Jones) [phone] [e-mail]
Name(s) Telephone Fax or E-mail address
2364 Swinson Farm Road Same
Current Mailing Address Current Street Address
Wendell NC 27591
City
8. Deed Book
State
18277 f 18292
Zip City
State
Zip
Page No. 2788 f 953 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):
CSSNC LLC [e-mail]
Name E-mail Address
2-634 Swinson Farm Road Same
Current Mailing Address
Wendell NC 27591
City State Zip
Telephone [phone]
Current Street Address
City
Fax Number
State
Zip

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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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:
Connie Jones
Name of Registered Agent
2634 Swinson Farm Road
Current Mailing Address
Wendell NC 27591
City
E-mail Address
Current Street Address
State Zip City
Telephone [phone] Fax Number.
State Zip
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.
Connie L. Jones
Type or print nai
Sig
Owner / Manager
Title or Authority
Date
9--zL;-zl
I, a Notary Public of the County of
State of North Carolina, hereby certify that ��11,(� �g�l!1� appeared
personally before me this day and being duty sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, thisday of , 20,22
TALENA LOY ^
NOTARY PUBLIC
Se hrston County
'North Carolina
My Commission Expires 9 /5
Notdry p
My commission expires.___