Financial Responsibility/ownership Form - Wake County

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WAKE COUNTY 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 Wake
County Unified Development Ordinance before this form and an acceptable erosion and
sedimentation control plan have been completed and approved by Wake County Department of
Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
1.
Project Name_______________________________________________________________________
2.
Location of land-disturbing activity: Jurisdiction ______________________ (Wake Co. or Municipality)
Highway/Street___________________ Latitude_________________ Longitude__________________
3.
Approximate date land-disturbing activity will commence: ____________________________________
4.
Type of development (residential, commercial, industrial, institutional, etc.):____________________
5.
Total
acreage
disturbed
or
uncovered
(including
off-site
utilities
and
borrow/waste
areas):_________________
6.
Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name________________________________
E-mail Address_______________________________
Telephone_________________________ Cell # ___________________ Fax # _________________
7.
Landowner(s) of Record (attach accompanied page to list additional owners):
____________________________________
________________________
_________________
Name(s)
Telephone
Fax or E-mail address
____________________________________
___________________________________________
Current Mailing Address
Current Street Address
____________________________________
___________________________________________
City
State
Zip
City
State
Zip
8.
Deed Book No._______________ Page No.______________ Provide a copy of the most current deed.
Part B.
1.
Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet. Include requested information):
____________________________________
___________________________________________
Name
E-mail Address
____________________________________
___________________________________________
Current Mailing Address
Current Street Address
____________________________________
___________________________________________
City
State
Zip
City
State
Zip
Telephone____________________________
Fax Number_________________________________

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