NCC223338_FRO Submitted_20220923

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(office Use Only]
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Durham County Stormwater
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
pr WITH LANDOWNER CONSENT FORM
No activity covered by the Durham County Stormwater Ordinance may be conducted until construction drawing
approval is issued by the Durham County 5tormwater and Erosion Control Division. Issuance of construction drawing
approval does not relieve the financially responsible party/owner of the obligation to obtain any other licenses,
permits and approvals as may be required by Federal, State, County or Municipal governments. A Stormwater
Permit will be issued upon final inspection and as -built approval. This office must be notified in writing of any
change to the information on this form.
PLEASE TYPE OR PRINT
1. Project name: 2427 Little River Drive
2. Road location of land -disturbing activity: 2427 Little River Drive
Tax Map - Block - Parcel: 230431 PIN: 0816-19-69-4044
3. Square footage of land to be disturbed or
uncovered:_56,793
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
Name Charles Ryan Flintom
Street Address 5717 N. Roxboro Rd.
Durham NC 27712
City _ State Zip
919-530-0559 N/A [e-mail]
Telephone Fax Email
S. 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 ❑isturbing Permit.
Name Charles Ryan Flintom
Street Address 5717 N. Roxboro Rd.
Durham NC 27712
City State zip
919-530-0559 N A Flintom @nc.rr.com
Telephone Fax Email
The Durham County Stormwater Ordinance (Ordinance) includes, but is not limited to, the following legal
obligations of the financially responsible party:
120 E. Parrish Street, Law Bldg., 1s' Floor, Durham, N.C. 27701 • [phone] ■ Fax [phone]

■ Install and maintain all stormwater control measures
■ Inspection and reporting by a registered professional engineer, registered land surveyor, or registered
landscape architect, upon the completion of their construction, and annually thereafter.
■ Maintain a set of approved stormwater control plans.
■ Maintain a performance band for the life of the project.
■ Maintain a valid stormwater permit.
F. For business applicants, list below the North Carolina registered agent for the financially responsible entity:
Name
Street Address
City State Zip
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; (Z) 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.
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Business Applicant Wrovicle corporate resolution on signatory authorit
I, , a Notary Public of the County of
State of
hereby certify that
personally came before me this day and acknowledged that he is
of
Witness my hand and official seal, this
and acknowledged, on behalf of
the due execution of the foregoing instrument.
day of
Notary Public
My commission expires 20
zo

Individual Applicant
I, Li 11►r{,r� C J u IL,
L a Notary Public of the County of n U V- m
State of N CA h (,& r D 1 + njL , hereby certify that 0,k&r") r t2 F ir.�nm
personally came before me this day and acknowledged that he is
0Wne-r
of �.� �+� Li��1����irr and acknowledged, on behalf of lrnSel
the due execution of the foregoing instrument.
Witness my hand and official seal, this f ` day of 2029
Public ��'� Notary-�[����
My commission expires ? 24�OpTAgA.
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Provide a Notarized Item 8 for each landowner listed in Item 4. 111111"Po
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.
11 MAY 2022 Charles Ryan Flintom
Date Type or Print Name
19-530-0559
Telephone
nc.rr.com
Fax
Tide c#Auth
Email Signature
Business Landowner Provide corporate resolution on signatory authority)
a Notary Public of the County of
State of , hereby certify that
personally came before me this day and acknowledged that he is
of
and acknowledged, on behalf of
the due execution of the foregoing instrument.
Witness my hand and official seal, this day of 20
Notary Public
My commission expires 0 20.

Individual Landowner
State of
a Notary Public of the County of
hereby certify that
personally came before me this day and acknowledged that he is
of
and acknowledged, on behalf of
the due execution of the foregoing instrument.
Witness my hand and official seal, this day of 120
My commission expires
20
Notary Public
Rev.08/17