NCC223098_FRO Submitted_20220901

Durham City/County
Sedimentation and Erosion Control
JCN
(Office Use Only)
[, FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
WITH LANDOWNER CONSENT FORM
No person may initiate any land -disturbing activity covered by the Durham City -County Unified Development Ordinance before a
Land Disturbing Permit is issued by the Sedimentation and Erosion Control Office. Issuance of a Land Disturbing Permit does not
relieve the permittee of the obligation to obtain any other licenses, permits and approvals as may be required by Federal, State,
County or Municipal governments. This office must be notified in writing of any change to the information on this form.
PLEASE TYPE OR PRINT
1. Project name: Stack Forest Private Paved Road and Private Gravel Driveway
2. Road location of land -disturbing activity: Bryan Place
Tax Map - Block - Parcel: _187045
3. Square footage of land to be disturbed or uncovered:_113,975
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
Richard Stack, Manager
Stack Forest, LLC
PO Box 867
New Bern, NC 28563
919-880-6691
Telephone
Fax
[e-mail]
Email
PIN: 0815-01-28-5176
5. List the person or entity financially responsible for this land -disturbing activity: The financially responsible party shall
be (1) the developer or other person who has or holds themselves as having financial or operational control over the land -
disturbing activity and/or (2) the land owner or person in possession or control of the land when they have directly or
indirectly allowed the land -disturbing activity or have benefited from it and (3) the named party on the Land Disturbing
Permit.
Richard Stack, Manager Stack Forest, LLC
Name
PO Box 867
Street Address
New Bern, NC 28563
City State Zip
919-880-6691
Telephone
Fax
[e-mail]
Email
The Sedimentation and Pollution Control Act (Act) and the Durham City -County Unified Development Ordinance
(Ordinance) includes, but is not limited to, the following legal obligations of the financially responsible party:
■ Maintain a set of approved sedimentation and erosion control plans, if required, on site.
■ Display permit on site.
■ Understand and implement any required plan, including the construction sequence and details.
■ Inspect, maintain and repair sedimentation and erosion control measures, especially after rainfall events.
■ Provided adequate ground cover or otherwise stabilize all areas that have not been actively graded within 21 calendar
days.
201 E. Main St, 5" Floor, Durham, N.C. 27701 • [phone] ! Fax [phone]
www.co.durham.nc.us/ceng

■ Plan and conduct all land -disturbing activity so as to prevent off -site sedimentation.
6. For business applicants, list below the North Carolina registered agent for the financially responsible entity:
WASLAW, LLC
1001 College Court
New Bern, NC 28562
252-672-5400 252-672-5477 [e-mail]
Telephone Fax Email
7. The above information is true and correct to the best of my knowledge and belief and was provided by me while under oath. I
understand that the person or entity listed on Line 5 above will be: (1) the owner of the Land Disturbing Permit when issued;
(2) responsible for ensuring compliance with the Act and Ordinance; and, (3) will be the only person or entity with standing to
appeal any action taken or decision made by the Sedimentation and Erosion Control Office.
July _, 2022 STACK FOREST, LLC/RICHARD STACK
Date Type or Print Name
Same as above Manager
Telephone Fax Title or Authority
Email Signature
Business Applicant (Provide corporate resolution on signatory authority)
I, , a Notary Public of the County of
State of
hereby certify that RICHARD STACK
personally came before me this day and acknowledged that he is MANAGER
of STACK FOREST, LLC and acknowledged, on behalf of STACK FOREST, LLC
the due execution of the foregoing instrument.
Witness my hand and official seal, this
My commission expires
20
day of July, 2022.
Notary Public
Individual Applicant
I, , a Notary Public of the County of
State
hereby certify that
personally appeared before me this date and under oath acknowledged that the above form was executed by them.
Witness my hand and official seal, this
My commission expires
day of
Notary Public
20
LAND DISTURBING PERMITS ARE NON -TRANSFERABLE
20

Provide a Notarized Item 8 for each landowner listed in Item 4.
8. Land Owner Consent. As a landowner, I provide my consent for land -disturbing activities to occur on the property listed in
Item 2 by the person or entity listed in Item 5.
July_, 2022
Date
same as above
Telephone
Email
STACK FOREST, LLGRICHARD STACK
Type or Print Name
Manager
Fax Title or Authority
Signature
Business Applicant (Provide corporate resolution on signatory authority)
I, , a Notary Public of the County of
State of
hereby certify that RICHARD STACK
personally came before me this day and acknowledged that he is MANAGER
of STACK FOREST, LLC and acknowledged, on behalf of STACK FOREST, LLC
the due execution of the foregoing instrument.
Witness my hand and official seal, this
day of July, 2022.
Notary Public
My commission expires 120
Individual Landowner
I,
a Notary Public of the County of
State of , hereby certify that
personally appeared before me this date and under oath acknowledged that the above form was executed by them.
Witness my hand and official seal, this
My commission expires
20
day of
Notary Public
20
SE-03 Rev.07/06
ND:4863-5427-7415, v. 1