NCC240026_FRO Submitted_20240104

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
WAKECounty 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
Noiirii cti1iE,��y� 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 Brixley Subdivision
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Pleasant Union Church Rd Latitude 35.96433 Longitude-78.65116
3. Approximate date land-disturbing activity will commence: January 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):? 8 acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Ryan Perry E-mail Address [e-mail]
Telephone [phone] Cell# Same Fax# N/A
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Pleasant 22 LLC 919.604.7120 [e-mail]
Name(s) Telephone Fax or E-mail address
5000 Falls of Neuse Rd, #100 Same
Current Mailing Address Current Street Address
Raleigh NC 27609
City State Zip City State Zip
8. Deed Book No. 19172 Page No. 1642-1648 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):
Pleasant 22 LLC [e-mail]
Name E-mail Address
5000 Fails of Neuse Rd, #100 Same
Current Mailing Address Current Street Address
Raleigh NC 27609 Same
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:
n/a n/a
Name E-mail Address
n/a n/a
Current Mailing Address Current Street Address
n/a n/a
City State Zip City State Zip
Telephone n/a 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:
James E. Allen, Jr. [e-mail]
Name of Registered Agent E-mail Address
5000 Falls of Neuse Rd, #100 Same
Current Mailing Address Current Street Address
Raleigh NC 27609
City State Zip City State Zip
Telephone [phone] Fax Number n/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.
Jim Allen Manager
Ty r print name Title or Authority
Si lure Date l 42—lig / -5
I, Ana4 01 / rli i R
, a Notary Public of t(hhe County of EJO
State of North Carolina, hereby certify that �1.i . r4 L V3 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 day of -D e., eAb 0 2
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