NCC231391_FRO Submitted_20230510

For TOWF Use Only Application #:
Project Name:
Date Received: Acres:
Date Approved: Fees Paid:
sr TOWN of
•
•
WAKE FOREST
LAND DISTURBING (E&SC)
PERMIT APPLICATION, PLAN CHECKLIST, &
FINANCIALLY RESPONSIBLE OWNER (FRO) FORM
No PERSON MAY INITIATE ANY LAND-DISTURBING ACTIVITY ON 1/2 ACRE OR MORE BEFORE THESE FORMS, FEES,AND AN
EROSION AND SEDIMENTATION CONTROL PLAN SEALED BY A NORTH CAROLINA REGISTERED PROFESSIONAL ENGINEER OR
LANDSCAPE ARCHITECT HAVE BEEN COMPLETED AND APPROVED BY THE TOWN OF WAKE FOREST. MULTIPLE SINGLE
FAMILY LOTS THAT DISTURB MORE THAN %z ACRE ALSO REQUIRE A PERMIT AND SHALL FOLLOW THE STANDARD
PROCEDURES OUTLINED BELOW. SEE THE UNIFIED DEVELOPMENT ORDINANCE FOR ADDITIONAL INFORMATION AND FULL
ORDINANCE REGULATIONS.
NOTE: THE APPLICATION FEE OF$500.00 PER ACRE(ROUNDED UP TO THE NEXT ACRE I.E.:1.1 ACRES = 2 ACRES*
$500=$1,000)IS DUE AT TIME OF SUBMITTAL. IF FEES ARE NOT SUBMITTED THE PLAN WILL AUTOMATICALLY BE
DISAPPROVED.
DISCLAIMER: TOWN OF WAKE FOREST FEES AND CHARGES ARE SUBJECT TO CHANGE WITHOUT NOTICE.
PLEASE CALL 919-435-9443 TO CONFIRM CURRENT FEES AND CHARGES.
PART A: PROJECT INFORMATION
PROJECT NAME WakeMed MOB
1. TAX PIN NUMBER 18400070540, 1840070859, 1830976175
2. ZONING NB NEIGHBORHOOD BUSINESS
3. LOCATION/ADDRESS OF TRACT 0 Siena Drive Wake Forest, NC

4. SUBDIVISION LOT#
5. DEED BOOK 17692 PAGE 424
*PLEASE PROVIDE A COPY OF THE MOST CURRENT DEED
6. PURPOSE OF DEVELOPMENT Medical Office Building
7. TOTAL NUMBER OF UNITS 1
8. PERCENT IMPERVIOUS SURFACE 31
9. TOTAL TRACT ACREAGE: 14.41
10. TOTAL ACREAGE DISTURBED (INCLUDING OFF-SITE UTILITIES AND ROADWORK):9.32
11. AMOUNT OF FEE ENCLOSED:
ROUNDED UP ACREAGE 10 * $50O/ACRE _ $ 5,000
CHECK NUMBER
DATE PAID
DISCLAIMER: Town of Wake Forest fees and charges are subject to change without notice. Please call 919-435-
9443 to confirm current fees and charges.
12. PROPERTY OWNER(S)(PROVIDE LIST OF ADDITIONAL PROPERTY OWNERS ON AN ATTACHED SHEET):
NAME WakeMed - Thomas Cavender E-MAIL [e-mail]
ADDRESS 3000 New Bern Ave Raleigh, NC 27610
PHONE [phone] CELL
13. PERSON TO CONTACT SHOULD EROSION AND SEDIMENT CONTROL ISSUES ARISE DURING LAND-DISTURBING ACTIVITY:
NAME E-MAIL
ADDRESS
PHONE CELL

14. PLANS PREPARED BY Stewart Engineering - Matthew McGinley PLA, Project Manager
ADDRESS 223 S. West St. Ste. 1100 Raleigh, NC 27603
EMAIL [e-mail]
PHONE [phone] CELL 979.571.9231
15. DOCUMENTS SUBMITTED (SUBMITTER TO PLACE A CHECK MARK IN THE BOX):
FEES ($500 per acre rounded up, due upon 1" review) V
FINANCIAL RESPONSIBILITY OWNER FORM V
COMPLETED PLAN CHECKLIST V
PLANS (to be submitted with construction set) V
E&SC CALCULATIONS (1 copy) ,
STORMWATER CALCULATIONS (1 copy) Y
MAINTENANCE AND OPERATION AGREEMENT
NCDOT Encroachment/Driveway Permit V
DWQ 401 Permit
USACOE 404 Permit
NCG010000 Permit COC
EROSION & SEDIMENT CONTROL SURETYV
APPROXIMATE DATE LAND-DISTURBING ACTIVITY WILL COMMENCE: March 2023
THE SOIL EROSION AND SEDIMENTATION CONTROL PLAN, supporting documents, maps and
computations submitted for the above tract conform to the requirements of all applicable
sections of the Town of Wake Forest Erosion & Sedimentation Control Ordinance outlined in
the UDO.
oi/L— Civil Engineer, PE 12/12/2022
SIGNATURE TITLE DATE

PART B. FINANCIALLY RESPONSIBLE OWNER (FRO)/PERSONS INFORMATION
1. PERSON(S)OR FIRMS WHO ARE FINANCIALLY RESPONSIBLE FOR THE LAND-DISTURBING ACTIVITY(PROVIDE A
COMPREHENSIVE LIST OF ALL RESPONSIBLE PARTIES ON AN ATTACHED SHEET):
WakeMed - Thomas Cavender [e-mail]
NAME EMAIL
3000 New Bern Ave
ADDRESS
Raleigh NC 27610
CITY STATE ZIP CODE
919.350.8098
PHONE CELL
2. IF THE FINANCIALLY RESPONSIBLE PARTY IS NOT A RESIDENT OF NORTH CAROLINA, GIVE NAME AND STREET ADDRESS OF
THE DESIGNATED NORTH CAROLINA AGENT:
NAME EMAIL
ADDRESS
CITY STATE ZIP CODE
PHONE CELL
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:
NAME OF REGISTERED AGENT E-MAIL ADDRESS
ADDRESS
CITY STATE ZIP

PHONE FAX
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.
do s Gw- lc,v 7".
AME TITLE OR AUTHORITY
Iail?1 022
IGNATURE DATE
I, ti AP,LL Gv 122 I Li.0 , a Notary Public of the County of
A1FE , State of North Carolina, hereby certify that
Ti-tom CA,vENDEAL— 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 I�. day of DC,irMc 12, , 20/2
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LAND DISTURBING (E&SC) PERMIT PLAN SUBMITTAL CHECKLIST
(SUBMITTER TO PLACE A CHECK MARK NEXT TO EACH ITEM)
1. LOCATION/VICINITY MAP
V] 2. EXISTING AND PROPOSED COUNTOURS, INCLUDING OFFSITE
3. CLEARLY DELINEATED BOUNDARIES OF LAND DISTURBANCE WITH ACREAGE
VA4. SOILS AREA MAP
Vi 5. DRAINAGE AREA MAP
Vi 6. EXISTING UTILITY EASEMENTS,STORM DRAINAGE, BASINS, LEVEL SPREADERS
Vi7. EXISTING LOT LINES, LOT NUMBERS, SURROUNDING PROPERTY OWNERS
Vi8. STREAM CENTERLINES,STREAM BUFFERS,WETLANDS, FLOODPLAINS
V] g TEMPORARY EROSION CONTROLS TO BE SHOWN ON PLANS:
1. EROSION CONTROL CALCULATIONS(SEDIMENT BASIN,SEDIMENT TRAP,
SKIMMER, DITCH, ETC...)
Vi2. SKIMMER BASINS REQUIRED FOR DRAINAGE AREA OVER 5 ACRES
3. IF PAM IS TO BE USED ONSITE FOR ANY APPLICATIONS,CALCULATIONS FOR
APPLICATION RATES AND SPECIFICATIONS MUST BE SHOWN. IN ADDITION,
SOIL TESTS MUST BE TAKEN TO DETERMINE CORRECT SOIL CHARGE AND
PRODUCT TYPE PRIOR TO USE.
I`/ I 4. CONSTRUCTION ENTRANCE 50 FOOT MINIMUM WITH WOVEN 20#
TENSILE STRENGTH FABRIC UNDERNEATH
SILT FENCE-METAL POSTS WITH WIRE SPACED AT 6 FEET
6. HARDWARE CLOTH OUTLETS(SPECIAL SEDIMENT CONTROL FENCE)
TV7. TREE PROTETION FENCE WITH "DO NOT ENTER TREE PROTECTION AREA"
SIGN IN ENGLISH AND SPANISH
i. REQUIRED AROUND PERIMETER OF
PROPERTY

ii. REQUIRED AT BUFFER ZONES
iii. REQUIRED IN TREE SAVE AREAS(AROUND
DRIP LINE)
8. DIVERSION DITCHES
9. INLET PROTECTION
71 to. EROSION
Vriii. PERMANENT EROSION/STORM WATER CONTROLS
i. STORMWATER CALCULATIONS, Q PRE,Q POST,%
IMPERVIOUS
ii. PROPOSED STORMWATER EASEMENTS(RECORDED)
iii. MAINTENANCE AND OPERATION AGREEMENT
iv. PROFESSIOANLLY SURVEYED AND ENGINEER STAMPED AS-
BUILTS OF STORMWATER PONDS/BIO CELLS, LEVEL
SPREADERS,STORM DRAINAGE INVERTS,TOPS, GRATES,
SLOPES, LENGTH, SIZE, ETC...
v. PERMANENT DITCHES WITH MATTING
VI°. EROSION PERMIT NOTES:(please add to plans)
1. A LAND DISTURBING(E&SC) PERMIT IS REQUIRED FOR PROJECTS OVER 0.50
ACRE.
IF MULTIPLE LOTS WITH LAND DISTURBANCE OVER 0.50 ACRE TOTAL ARE
EITHER CONTIGUOUS OR NON-CONTIGUOUS IN THE SAME SUBDIVISION, BY
THE SAME BUILDER/OWNER,A LAND DISTURBING PERMIT IS REQUIRED.
THE COST OF THE PLAN REVIEW AND PERMIT IS$500/ACRE ROUNDED UP(1.1
ACRES=2 ACRES @ $500/ACRE =$1,000). THE FEE IS DUE AT TIME OF PLAN
SUBMITTAL. DEVELOPER IS RESPONSIBLE FOR INFORMING BUILDER OF E&SC
PERMIT REQUIREMENTS ON INDIVIDUAL LOTS.
DISCLAIMER: Town of Wake Forest fees and charges are subject to change
without notice. Please call 919-435-9443 to confirm current fees and charges.
2. IF ADDITIONAL ACREAGE IS ADDED TO AN EXISTING PERMIT REVISED FORMS,
PLANS, AND ANY ADDITIONAL FEES MUST BE SUBMITTED.
3. IF OWNERSHIP OF A PROPERTY HAS CHANGED A REVISED FRO MUST BE
SUBMITTED.
4. IF A PROPERTY IS TAKEN OVER BY THE BANK,THE BANK SHALL CONTACT THE
TOWN AND REPAIR ALL EROSION CONTROL MEASURES TO TOWN/NCDENR
STANDARDS. THEY SHALL ALSO SUBMIT A NEW FRO FORM.
5. IF A PROJECT IS NOT COMPLETE WITHIN TWO YEARS,THE PLANS MUST BE
RENEWED AT$250/ACRE.A REVISED SET OF PLANS MAY BE SUBMITTED IF
ACREAGE HAS ALREADY BEEN DEVELOPED AND A CERTIFICATE OF OCCUPANY
HAS BEEN ISSUED.

6. AN EROSION PRECONSTRUCTION MEETING MUST BE HELD WITH THE TOWN OF
WAKE FOREST PRIOR TO START OF ANY WORK, INCLUDING INSTALLATION OF
EROSION CONTROL MEASURES, DEMOLITION, CUTTING TREES,AND
GRUBBING.
CALL ENGINEERING AT(919)435-9443 TO SET UP A MEETING. ALL PLANS MUST
BE SIGNED AND COPIES RETURNED TO THE TOWN 1 WEEK PRIOR TO
PRECONSTRUCTION MEETING.
7. THE OWNER,GENERAL CONTRACTOR, GRADING COMPANY,AND EROSION
CONTROL INSTALLER MSUT BE PRESENT AT THE PRECONSTRUCITON MEETING.
8. THE E&SC PERMIT WILL BE DISTRIBUTED AT THIS MEETING.
ii. E&SC CONSTRUCTION SEQUENCE NOTES: (please add to plans)
1. PRIOR TO SCHEDULING THE PRECONSTRUCTION MEETING, THE EROSION AND
SEDIMENT CONTROL SURETY MUST BE SUBMITTED TO THE TOWN OF WAKE
FOREST.THE NCG010000 CERTIFICATE OF COVERAGE MUST BE OBTAINIED BY
THE PERMITTEE,WHEN APPLICABLE.A COPY OF THE COC MUST BE SUBMITTED
TO THE TOWN.
2. AFTER THE PRECONSTRUCITON MEETING IS HELD,THE CONTRACTOR CAN
INSTALL INITIAL EROSION CONTROL MEASURES ONLY. THIS INCLUDES BUT IS
NOT LIMITED TO CONSTRUCTION ENTRANCE,SILT FENCE, PERIMETER
DIVERSION DITCH,CHECK DAMS(ROCK OR WADDLE TYPE),TREE PROTECTION
FENCE, EXISITNG INLET PROTECTION, SKIMMER SEDIMENT BASINS,AND
SEDIMENT TRAPS. CLEAR ONLY AS NECESSARY TO INSTALL THESE MEASURES.
3. CONTRACTOR IS RESPONSIBLE FOR E&SC WEEKLY INSTALLATION AND
MAINTENANCE LOG INCLUDING DATES OF TEMPORARY/PERMANENT
GROUND COVER,A RAIN GAUGE, COPY OF TOWF SIGNED PLANS ONSITE,
REVISED SIGNED PLANS, NPDES LOG, AND CONSTRUCTION BOX MUST BE
PRESENT AND EASILY ACCESSABLE ONSITE.
4. ONCE MEASURES ARE INSTALLED, CONTRACTOR/FRO TO CALL TOWF FOR AN
INITIAL INSPECTION. IF SITE PASSES INSPECTION,A CERTIFICATE OF
COMPLIANCE WILL BE ISSUED. CONTRACTOR CAN NOW BEING CLEARING,
GRUBBING,AND GRADING.
5. CONTRACTOR TO MAINTAIN ACCESS ROAD FOR EMERGENCIES AT ALL TIMES.
6. PHASE PROJECT TO LEAVE AS LITTLE GROUND OPEN AS POSSIBLE.
7. TEMPORARILY SEED,STRAW AND TACK OR HYDROSEED WITHIN 14 DAYS OF
ANY PHASE OF GRADING, INCLUDING SLOPES. SEED BASINS AND DITCHES
IMMEDITEALY AFTER CONSTRUCTION.
8. PRIOR TO REMOVAL OF TEMPORARY MEASURES,TOWN MUST APPROVE
REMOVAL. ALL AREAS ABOVE TEMPORARY MEASURE MUST HAVE 85%
GROUND COVER.
9. THE TOWN OF WAKE FOREST CONSTRUCTION INSPECTOR WILL EVAULATE THE
SITE ATLEAST ONCE A MONTH.A COPY OF THE INSPECTION FORM WILL BE
EMAILED TO THE FRO.THE WEEKLY EROSION LOG AND NPDES LOG MUST BE
ONSITE AND AVAILABLE FOR REVIEW.
10. IF THE SITE IS FOUND OUT OF COMPLIANCE A NOTICE OF VIOLATION WILL BE
ISSUED GIVING THE CONTRACTOR/FRO 7 WORKING DAYS TO REMEDY THE
PROBLEM. IF THE SITUATION IS NOT RESOLVED WITHIN THE TIME PERIOD A
FINE MAY BE ISSUED.
11. IF SEDIMENT LEAVES THE SITE A FINE MAY BE ISSUED UP TO$5,000 PER DAY

PER VIOLATION. IF SEDIMENT ENTERS A BUFFER,STREAM,OR WETLAND
NCDWQ WILL BE NOTIFIED.THEY MAY ISSUE FINES UP TO$25,000 PER DAY PER
VIOLATION.
12. CALL THE TOWN UPON COMPLETION FOR A FINAL EROSION INSPECTION.A
PUNCHLIST MAY BE GENEREATED ADDRESSING ANY REMAINING ITEMS.
THERE MUST BE 85%GROUNDCOVER ON THE ENTIRE SITE PRIOR TO A
CERTIFICATE OF OCCUPANCY. IF THE SITE IS FOUND TO BE IN COMPLIANCE
AN EROSION CERTIFICATE OF COMPLETION WILL BE ISSUED. AFTER THE
COMPLETION OF THE PROJECT,SUBMIT A NOTICE OF TERMINATION TO END
COVERAGE UNDER THE NCG01000 PERMIT.