NCC232796_FRO Submitted_20231004

DURHAM JCN
COUNTY Durham City/County (Office Use Only)
e7r-:, Sedimentation and Erosion Control
Fg4 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
1,VIVAI,-,
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: Copper Run South Extension: Yes or No
2. Road location of land-disturbing activity: HWY 70 and Angier Road
Tax Map-Block-Parcel: See Below PIN: See Below
3. Square footage of land to be disturbed or uncovered: 21 .03 Acres
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate page):
Forestar (USA) Real Estate Group, Inc.
Name
8041 Arco Corporate Dr, Suite 110
Address
Raleigh NC 27617
City State Zip
919-804-7220 N/A [e-mail]
Telephone Fax Email
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.
Forestar (USA) Real Estate Group, Inc.
Name
8041 Arco Corporate Dr, Suite 110
Street Address
Raleigh NC 27617
City State Zip
9 4 275-9094 N/A
( $ ) [e-mail]
Telephone Fax Email
i 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.
• Plan and conduct all land-disturbing activity so as to prevent off-site sedimentation.
201 E.Main St,5th Floor,Durham,N.C.27701 •[phone] •Fax[phone]
1 www.co.durham.nc.us/ceng

6. For business applicants,list below the North Carolina registered agent for the financially responsible entity:
Forestar (USA) Real Estate Group. Inc.
Name
2626 Glenwood Avenue, Suite 550
Street Address
Raleigh NC 27608
City State Zip
919-804-7220 N/A [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.
9/1/23 Megan Lynn Mueller
Date Type or Print Name
919-804-7220 Vice President
Telephone Fax thority
[e-mail]
Email Signatur
********* *:******:********************************************:*********** *t *********************************************
Business Applicant(Provide corporate resolution on signatory authority)
I, p1MKJA CtuW t7 ,a Notary Public of the County of \/ J XJ .
State of N.ok'(I-I CA1&DL1 tJA- ,hereby certify that MIE,64,ki l >t.l Mt M,UEU.F,42
personally came before me this day and acknowledged that he is f t.( 1?'("�S t D 1"tat!C.
\\\of 3.4p&sp\2i�
� ALFATACC 62i)1.(,Pand acknowledged,on behalf of t`OI:EStaZ.Cu.Sa) REAL r i4, L2vU P 1I11G .
O ff, s ,the due execution of the foregoing instrument.
O Notary Public 'fh
WOrrim Rhf?nd and fficial seal,this S day of S F 14B£ ,20 2 3
=My Commission Expires_
2 =" Notary ublic
''A!"x Hmmi � 'e Tres 4 U ,20 Z
*************I ******************************************************************************************************************
Individual Applicant
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 day of ,20
Notary Public
My commission expires 20
LAND DISTURBING PERMITS ARE NON-TRANSFERABLE

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.
09/01/23 Megan Lynn Mueller
Date Type or Print Name
919-804-7220 Vice President
Telephone Fax Title or Authority
MLMueller@a forestar.com
Email Signature
***********************************************************************************************************************************
Business Landowner(Provide corporate resolution on signatory authority)
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 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 ,20
*********************************************************************************************************************************
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 day of ,20
Notary Public
My commission expires 20
SE-03 Rev.07/06
Copper Run South REID/PIN
Tract(From
REID PIN ALTA) Seller Seller Address Acreage SF
235122 0749-98-0335 Tract 1 WELLONS CHARLES R FOUNDATION PO BOX 52328 1.85 80399
235123 0749-98-4596 Tract2 HAMLETT,CHARLENE W,WELLONS,MIRIAM A PO BOX52328 7.56 329489
235125 0749-98-9953 Tract 3 HAMLETT,CHARLENE W,WELLONS,MIRIAM A PO BOX 52328 1.08 47157
235126 0749-98-9415 Tract4 WELLONS CHARLES R FOUNDATION PO BOX52328 10.02 436291
235128 0759-08-3371 Tracts REA LANDCOM INC 3333 DURHAM CHAPEL HILL BLVD STE C 7.33 319327