NCC221858_FRO Submitted_20220516

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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.
1Project Name 5T1204 Carpenter Fire Station Rd Realignment - Adding Phillips Pond Dam Rehabilitation (0.70 Acres)
.
2. Location of land -disturbing activity: County Wake City or Township Cary ETJ White Oak
S R 1 624 35.824554°-78.872894°
Highway/Street Latltude(decimaldegrees) LOngltude(decimaldegrees)
3. Approximate date land -disturbing activity will commence: June 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Maintenance and rea
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 21.92 (20 acres paid)
6. Amount of fee enclosed $350 ($250 and $100) The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). 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 Robert E. Shultes E-mail Address [e-mail]
Phone: Office # [phone] Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Phillips Family Holdings, LLC [phone] [phone]
Name Phone: Office # Mobile #
6701 Good Hope Church Rd 6701 Good Hope Church Rd
Current Mailing Address Current Street Address
Cary NC 27519-8869 Cary NC 27519-8869
City State Zip City State Zip
10. Deed Book No. 017915 Page No 01510 Provide a copy of the most current deed

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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Engineering firm or other consultant
Individual contact person (type or print)
E-mail Address
Phone: Office # Mobile #
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.
Robert E. Shultes
Type
or print name
ligitally by Robert E.
Robert
E. Shultes Date: 2022.pfip213:26:35-0400tes
Signature
---------------------------
Michelle Carr
Senior Construction Manager
Title or Authority
5/2/02
Date
, a Notary Public of the County of
Wake
State of North Carolina, hereby certify that Robert E. Shultes 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 2nd day of May , 2022
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My commission expires 03-25-2026

INSPECTIONS & PERMITS DEPARTMENT
April 21, 2022
Phillips Family Holdings, LLC Wake County PIN#: 0735758029
Mr. Paul Lee Phillips Wake County RE ID#: 0354016
Mrs. Sue Bradley Phillips Deed Book 017915, Deed Page 01510-01511
6701 Good Hope Church Road BM 2006, Page 01746
Cary, NC 27519-8869
Project: ST1204, WT1097 & WT1283 - Carpenter Fire Station Road Realignment and Grade
Separation Project with CSX Railroad - CSX Project NC0750
Subject: Written Consent for Town of Cary To Submit Draft Erosion Control and
Sedimentation Control Plan for Anticipated Land Disturbing Activity
Dear Mr. and Mrs. Phillips,
The Town of Cary is required to submit a draft erosion and sedimentation and erosion control plan to the
North Carolina Department of Environmental Quality (NCDEQ). This step is necessary for the additional
work on your property to satisfactorily perform the repair and rehabilitation of the Phillips Pond Dam
parallel to CSX Rights of Way. This footprint area was not included in the approved drawings and permits
at the time of permitting the above referenced project.
Designs are nearing completion with the Town's consultant on the pond repairs, and we need to initiate
the necessary permit modifications to include this work as part of the above referenced project footprint.
The Town of Cary is the financial responsible party for this environmental permit modification.
As required by the attached Financial Responsibility Form from NCDEQ to initiate the draft plan, review
we need your signature(s) with dates acknowledging your consent for the Town of Cary to submit a draft
erosion and sedimentation control plan to conduct the future land disturbing activities as part of the pond
rehabilitation plans.
If you agree to provide your consent to allow the Town to submit the erosion control plan to NCDEQ,
please sign where noted below with a date and return to my attention.
Consent and agreed to:
By: ji�t, Date: s
2 �--/j r-)
Mr. Paul Lee Phillips
7
By: Date: w
Mrs. Sue d ey Phill'
If you have any questions, please contact me at [phone] Mobile or by email at
bob. shultes townofcar .or .
Sincerely,
1'-A-0
Robert E. Shultes
Senior Construction Manager
TOWN Of CARY
316 North Academy Street • Cary, NC 27513 • PO Box 8005 • Cary, NC 27512-8005
te1919-469-4030 • fax [phone] • www.townofcary.org