NCC232288_FRO Submitted_20230801

DURHAM JCN -co U N T V Durham City/County (Office Use Only)
Sedimentation and Erosion Control
13E0 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
"� WITH LANDOWNER CONSENT FORM
1881
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: Extension:KENNEBEC DRIVE Extension: Yes or No
2. Road location of land-disturbing activity: 8022 KENNEBEC DRIVE
Tax Map-Block-Parcel: 143201 PIN: 0707-20-42-4684
3. Square footage of land to be disturbed or uncovered: 215981 SF
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate page):
LARRY DONNELL THOMPSON. DEBORAH CARR THOMPSON
Name
100 N BEACH BLVD., UNIT 419
Address
NORTH MYRTLE BEACH SC 29582
City State Zip
843-359-4866 donnellthompson99Ca�gmail.com
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.
DONNELL THOMPSON
Name
100 N BEACH BLVD., UNIT 419
Street Address
NORTH MYRTLE BEACH SC 29582
City State Zip
843-359-4866 donnellthompson99agmail.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:
• 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

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.
DONNELL THOMPSON
Date Type or Print Name
843-359-4866 OWN
Telephone Fax T' ut rity
[e-mail]
Email Signature
***********************************************************************************************************************************
Business Landowner(Provide corporate resolution on signatory authority)
h ,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
,a Notary Public of the County of A 61.
State of elitli6kik ,hereby certify that V .1\' 0\2464,93/1
personally appeared before me this date and under oath acknowledged that the above form was e uted by them.
Witness my hand and official seal,this 1tg^ day of u ,20 a 3
Notary Public
My commission expir 1k 20 Di
,,,01111111,,
SE-03 C,1r1�►A /0 Rev.07/06
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■ 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 action taken or decision made by the Sedimentation and Erosion Control Office.
DONNELL THOMPSON
Date Type or Print Name
843-359-4866 OW
Telephone Fax Tit .. uthoc y
1.
donnellthompson99(a gmail.com ,�/'
Email
„nature
Business Applicant(Provide corporate resolution on signatory authority J
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 Applicant -I,L \ t tel�S ,a Notary Public of the County ofC6.A1
State of 9lA ,hereby certify that 1 As t1 1 1f.4,mtSUfl
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 w'"fk day of OVA.) a 0►1 t 11 ieii,
.�` 5NA A Vie fe,
Notary Public = a aOT4k. fin!Q
My commission expires ) (CL -alit O3 m geoe'BIAG C: F.
LAND DISTURBING PERMITS ARE NON-TRANSFERABLE .,0 t• pUNIA��•`�$