Fillable FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT Part (Clayton, North Carolina)

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT Part (Clayton, North Carolina)

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Town of Clayton
Soil Erosion and Sedimentation Control Ordinance before this form and an acceptable erosion and
sedimentation control plan have been completed and approved by the Town of Clayton. (Please type or print
and, if the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name_______________________________________________________________________
2. Location of land-disturbing activity: County JOHNSTON City or Township CLAYTON
Hi
ghway/Street___________________ Latitude_________________ Longitude__________________
3. Appr
oximate date land-disturbing activity will commence:_____________________________________
4. Pur
pose of development (residential, commercial, industrial, institutional, etc.):____________________
5. Tot
al acreage disturbed or uncovered (including off-site borrow and waste areas):_________________
6. Amo
unt of fee enclosed: $____________________. [The fee of $125 per acre (rounded up to the next
acre) is assessed without a ceiling amount; Single Family lot - $75] .
7. Has an erosion and sediment control plan been filed? Yes________ No________ Enclosed_________
8. Per
son to contact should erosion and
sediment control issues arise during land-disturbing activity:
Name
________________________________ E-mail Address_______________________________
Tel
ephone_________________________ Cell # ___________________ Fax # _________________
9. Landowner(s) of Record (attach accompanied page to list additional owners):
_______
_____________________________ ________________________ _________________
Name Telephone Fax Number
_______
_____________________________ ___________________________________________
Current Mailing Address Current Street Address
_______
_____________________________ ___________________________________________
City State Zip City State Zip
10. Deed
Book No._______________ Page No.______________ Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.)
If the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
____________________________________ ___________________________________________
Name E-mail Address
_______
_____________________________ ___________________________________________
Current Mailing Address Current Street Address
____________________________________ ___________________________________________
City State Zip City State Zip
Tel
ephone____________________________ Fax Number_________________________________
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of
the designated North Carolina Agent:
_____________________________________ ___________________________________________
Name E-mail Address
_____________________________________ ___________________________________________
Current Mailing Address Current Street Address
_____________________________________ ___________________________________________
City State Zip City State Zip
Telephone_____________________________ Fax Number_________________________________
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible Party
is a Corporation, give name and street address of the Registered Agent:
_____________________________________ ___________________________________________
Name of Registered Agent E-mail Address
_____________________________________ ___________________________________________
Current Mailing Address Current Street Address
_____________________________________ ___________________________________________
City State Zip City State Zip
Telephone_____________________________ Fax Number_________________________________
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
_____________________________________ _______________________________________
Type or print name Title or Authority
_____________________________________ _______________________________________
Signature Date
------------------------------------------------------------------------------------------------------------------------------------
I, __________________________________, a Notary Public of the County of _________________
State of North Carolina, hereby certify that _____________________________________ appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this ______day of _________________, 20_______
_______________________________________
Notary
Seal
My commission expires_____________________
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FINANCIAL RESPONSIBILITYOWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT Part (Clayton, North Carolina)

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Completed 22 January 2021

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