NCC233817_FRO Submitted_20240103

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.
1. Project Name Fuquay-Varina Southern Oaks Gravity Sewer Outfall - Phase II
2. Location of land-disturbing activity: County Wake City or Township Fuquay-Varina
Wagstaff Rd.to Bowling Rd. 35.566635 -78.809735
Highway/Street Latitude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 1/2/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): municipal sewer
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 7'23
6. Amount of fee enclosed $2,800.00 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 El No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Clark Maness E-mail Address [e-mail]
Phone: office# 919-469-3340 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Currin, Ronald J.
Name Phone: Office# Mobile#
117 Progress Drive 117 Progress Drive
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Page No. 1216
10. Deed Book No. 18696 Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Town of Fuquay-Varina [e-mail]
Company Name E-mail Address
134 N. Main Street 134 N. Main Street
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Phone: Office# 919-552-1401 Mobile#
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General

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:
WithersRavenel [e-mail]
Engineering firm or other consultant E-mail Address
Clark Maness 919-469-3340 919-535-5213
Individual contact person (type or print) 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.
Adam Mitchell Town Manager
Type or pr. t nam Title or Authority
S.g nature Date
I. �Q ,. CAf.J1. , a Notary Public of the County of ViG,ke
State of North Carolina, hereby certify that IklaVvt 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,U day of Na Vn,6f/ , 20 2.3
ESA c \ Notary
My commission expires 3/S/ 20-2-6
nr ,)

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Carriage Heights Owners Association, Inc.
Name Phone: Office# Mobile#
4917 Waters Edge Dr., Ste. 140 4917 Waters Edge Dr., Ste. 140
Current Mailing Address Current Street Address
Raleigh NC 27606 Raleigh NC 27606
City State Zip City State Zip
Deed Book No. 18861 Page No. 1364 Provide a copy of the most current deed.
Landowner 3 of Record.
The Ridge at Kenneth Creek HOA
Name Phone: Office# Mobile#
4112 Blue Ridge Rd., Ste. 100 4112 Blue Ridge Rd., Ste. 100
Current Mailing Address Current Street Address
Raleigh NC 27612 Raleigh NC 27612
City State Zip City State Zip
Deed Book No. 17792 Page No. 1917 Provide a copy of the most current deed.
Landowner 4 of Record:
Parker Pointe HOA
Name Phone: Office# Mobile#
1210 Trinity Rd., Ste 102 1210 Trinity Rd., Ste 102
Current Mailing Address Current Street Address
Cary NC 27513 Cary NC 27513
City State Zip City State Zip
Deed Book No. 16254 Page No.2752 Provide a copy of the most current deed.
Landowner 5 of Record:
Parker Pointe HOA
Name Phone: Office# Mobile#
1210 Trinity Rd., Ste 102 1210 Trinity Rd., Ste 102
Current Mailing Address Current Street Address
Cary NC 27513 Cary NC 27513
City State Zip City State Zip
Deed Book No. 16254 Page No.2756 Provide a copy of the most current deed.

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 6 of Record-
Haase, David F., Sheila
Name Phone: Office# Mobile#
603 Fleming Loop Rd. 603 Fleming Loop Rd.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No. 18403 Page No.293 Provide a copy of the most current deed.
Landowner 7 of Record:
Thompson, Eric S., Dorothy A,
Name Phone: Office# Mobile#
700 Fleming Loop Rd. 700 Fleming Loop Rd.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No. 3498_ Page No.540 Provide a copy of the most current deed.
Landowner 8 of Record:
Currin, Glenn
Name Phone: Office# Mobile#
PO Box 716 PO Box 716
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No. 17065 Page No.2248 Provide a copy of the most current deed.
Landowner 9 of Record:
Town of Fuquay-Varina 919-567-3919
Name Phone: Office# Mobile#
134 N. Main St. 134 N. Main St.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No.2759 Page No:498 Provide a copy of the most current deed.

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 10 of Record
Mark & Steve Investments, LLC
Name Phone: Office# Mobile#
908 W. Academy St. 908 W. Academy St.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No. 17055 Page No.2262 Provide a copy of the most current deed.
Landowner 11 of Record:
Mark & Steve Investments, LLC
Name Phone: Office# Mobile#
908 W. Academy St. 908 W. Academy St.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No. 18246 Page No. 164 Provide a copy of the most current deed.
Landowner 12 of Record:
RP One LLC
Name Phone: Office# Mobile#
5320 Umstead Rd. 1102 Phelps West Rd.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No. 13188 Page No. 1527 Provide a copy of the most current deed.
Landowner 13 of Record:
Barley, Matthew; Bounkazi, Ornelie
Name Phone: Office# Mobile#
1032 Phelps West Rd. 1032 Phelps West Rd.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No. 19176 Page No.2441 Provide a copy of the most current deed.

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 14 of Record:
Samala, Sneha G., Vivek
Name Phone: Office# Mobile#
1028 Phelps West Rd. 1028 Phelps West Rd.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No. 19012 Page No.2066 Provide a copy of the most current deed.
Landowner 15 of Record:
Roberts, Matthew D., Rebecca L.
Name Phone: Office# Mobile#
1024 Phelps West Rd. 1024 Phelps West Rd.
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Deed Book No. 16734 Page No.2764 Provide a copy of the most current deed.
Landowner 16 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. _ Provide a copy of the most current deed.
Landowner 17 of Record.
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.