NCC232559_FRO Submitted_20230829

DURHAM JCN
C O U N T Y Durham City/County (Office Use Only)
Sedimentation and Erosion Control
A eh 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 pernuttee 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: PROJECT BLUE JAY: PHASE 2
2. Road location of land-disturbing activity: SO HI DRIVE 35.940584, -78.868978
Tax Map-Block-Parcel: 225017, 228347 PIN:0739-86-15-8174.RTP,0739-86-15-8174.SRV
3. Square footage of land to be disturbed or uncovered: 7.54 AC
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate page):
ELI LILLY AND COMPANY, an Indiana corporation
Name
LILLY CORPORATE CENTER - 893 DELAWARE ST
Address
INDIANAPOLIS INDIANA 46285
City State Zip
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.
Daniel Lee VonDielingen
Name
59 Moore Drive, P.O. Box 110047
Street Address Durham North Carolina 27709
City State Zip
[phone] vondielingen daniel [e-mail]
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 fmancially 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,5th 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:
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 actiontaken or decision made by the Sedimentation and Erosion Control ,Of/fice. )�
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Email Signature
Business Applicant(Provide corporate resolution on signatory authority)
I, CA tc Lavi-e ,a Notary Public of the County of el , /r1V i
State of NUY1-h ('i 'C)I I rl�� ,hereby certify that •ha nit" ► c V C)V1c\
personally came before me this day and acknowledged that he is V IC C PCe<)i clop�- J
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of C I i Lt I1, �tL�W1,,,,, and acknowledged,on behalf of Cf'%t L► kl t_t C .4 Invyn r,,,r`''` �'l'ksiie,�
,the due execution of the foregoing instrument. aJ°�C snd
Witness my hand and official seal,this F
No ublie G I4YMy commission expires �r1r1 I C ,20 3 . 3��
41,11/ 1
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.
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Email / Signature
Business Landowner(Provide corporate resolution on signatory authority)IJt(o i('4`J i�c-)e t _4-1 a l-C ,a Notary Public of the County of C1v 2l V/��1 t e
State of 1\61 4-11 QAvLl ,hereby certify that t I�rl c \ 1�J7L�e nd I e \in 1�
personally came before me this day and acknowledged that he is V ICE �t1'(')%C��✓ll J
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of Cry 1 �--►( y ('[�VYI �'�ny and acknowledged,on behalf of �I I I`i(1�.1 CUy�p��Y� _ �0
,the due execution of the foregoing instrument. A,0 c.
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Witness my hand and official seal,this ifs*ir\ day Ma_ ,2 f Z
O n
No ublic , -1,
1
My commission expires ��nck-- t C� ,20oZ 3 . , �Ny1 sfttftioomisoiov,�`�
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