NCC230104_FRO Submitted (2)_20230113

e JCN
r Durliam City/County (once Use only)
Sedimentation and Erosion Control
rFINANCIAL RESPONSIBILITY/OWNERSHIP FORM
WITH LANDOWNER CONSENT FORM
No person may initiate any land -disturbing activity covered by the Durha€n 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: Olive Branch Sewer Outfall
2. Road location of land -disturbing activity:_ Olive Branch Road (lattitude 35.959600, longitude-78.768230)
Tax Map - Block - Parcel: 194192 PIN: 0860-03-84-5286
3. Square footage of land to be disturbed or uncovered: 81,189 S.F. (1.86 AC.) _
4. List below the landowner of record. Each landowner must complete Item S
(If there are multiple owners, please list on a separate page):
Erik F Hauck. Nicole Maria Hauck
Name
1001 Hidden Trail Ct
Address
Wake Forest NC 27587
City State Zip
Telephone Fax Email
5. List the person or entity financially responsible for this Iand-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 tile land -disturbing activity or have benefited from it and (3) the named party on the Land Disturbing
Permit.
Pulte Home Comoanv. LLC
Name
1225 Crescent Green Drive Suite 250
Street Address
Cary NG
City State
Zip
919-816-1146 n1a
chris.raughlev0pultegroun.com
Telephone Fax
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:
a Maintain a set of approved sedimentation and erosion control plans, if required, on site.
Display permit on site.
u 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.
e Provided adequate ground cover or otherwise stabilize all areas that have not been actively graded within 21 calendar
days.
201 E. Main St, 5111 Floor, Darbam, N.C. 27701. a [phone] • Fax [phone]
iywm-.co.durham.nc.uslccng

w Plan and conduct all land -disturbing activity so as to prevent off -site sedimentation.
5. 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;
(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.
zlr`y f 22 Chris Rauohley
Date Type or Print Name
VP Land Development
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Telephone Fax Title or Au ity
In r i S .. t" a v, � a '�',. > % ��
Email Signature
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Business Applicant (Provide corporate resolution on signatory authority)
1, r, or, �I t rru l � � , a Notary Public of the County of. W'X le -e—
State of /V C. hereby certify that C_ rh t-; s i e V
personally came before me this day and acknowledged that lie is _ V i C C_ PreS, rke,
of Oe Y �e W,� e ,t and acknowlcdged, on behalf of f t j �-�—'
the due execution of the foregoing instrument.
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Witness my hand and official seal, this day of ' 1?ri,tcL V'
--� Notary Public
My commission expires 20 L
Individual Applicant 'ottiliitlt1//'
I, a Notary Public of the County of
State of ,hereby certify that +~_�/0
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personally appeared before me this date and under oath acknowledged that the above form wags executeaN ton,
Witness my hand and official seal, this day of �'< 0
Notary Public
My commission expires 20
LAND DISTURBING PERMITS ARE NON -TRANSFERABLE

8.
Provide a Notarized Item 8 for each landowner listed in Item 4.
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.
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Teleph no Fax Title or uth ri rd
Email
Signature
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Business Landowner(Provide corporate_ resolution on signatory authority
I, , a Notary Public of the County of
State of , hereby certify that
personally came before the this day and acknowledged that lie is
Of
Witness my hand and official seal, this
My commission expires
and acknowledged, on behalf of
the due execution of the foregoing instrument.
day of
Notary Public
20
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)Individual Landowner
1, nn; c� er , a Notary Public of the County of Olam' «-r—
20
State of LJL_ arb�,`YiG , hereby certify that J� Z cdl P. KL\rI a - Ph.,ll —S kl e\ )?c.t' t Evt c Prreclf zc.>n Ao1
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 ��i5 tV 20. a JL
Not Pu lic
My commission expires 20_ 9--7
U_
S E - 0 3
My Comm. ExP• -=
05-24-2027
�y.
i..�@ C o V"It.31'df
Rev.07106