NCC230368_FRO Submitted_20230208

__ , %7
INSPEIONS
DIVISION
Excellence through Service
Single -Family Dwelling
City of WlJnston Salem
Erosion Control Affidavit Operations
Bryce A. Stuart Municipal Building
Suite 328
100 E. First Street
Winston-Salem, NC 27101
P.O. Box 2511
Winston-Salem, NC 27102-2511
This affidavit must be submitted at the time of the building permit appit lication. Phone: [phone]
Fax: [phone]
Date; / - / 3 - Z d Z. 3
Permit
Job Site Address: /d 23 CCaMpasa R& 3 c Co L4,u- I
Subdivision Name: 066 � v/:,cw [:.r Ia �9 t Parcel Pin # 70 - 3a G 3
Land area to be disturbed during construction (sq. ft. or acres): JD, o do
General Contractor:
Address: !P 6 & k -9 y "J
City/State/Zip: L V fv;; U iL o NK 2? 6 Z 7 Office Phone: 33G �� L• i 7 4 3
Mobile Phone: '-!G •• /7g3 Fax Number: Email: S/"(, i?77 �w►a.l. CeT
My signature hereto signifies I am the owner/financially responsible party for job site compliance with the Erosion Control Ordinance
as outlined in Chapter, Section 4 of the Unified Development Ordinances (UDO) of the City of Winston-Salem/Forsyth County or
Article IV of the UDO of the Village of Clemmons, Town of Lewisville, or Town of Walkertown. I hereby acknowledge that Best
Management Practices must be used to control soil erosion on my job site to include but not be limited to the following:
1. Installation and regular maintenance of silt fencing using the preferred method of trenching installation on all low/down slope
sides of my job site. Silt fence is to have an upslope return at each end no less than 5 feet. Silt Fence must be installed to
meet the minimum standards as specified in the North Carolina Erosion and Sediment Control Planning and Design Manual
Section 6.62 (Link: http://deg.nc.gov/abouVdivisions/energy-mineral-land-resources/energy-mineral-land-permit-
quidance/erosion-sediment-control-planning-design-manual); and
2. Installation and regular maintenance of a stone construction entrance. The stone construction entrance shall consist of a 2
inch to 3 inch coarse washed aggregate stone. Construction entrance shall be a minimum 6 inches in thickness, minimum of
12 foot wide extended to the structure or 50 feet in length if site conditions allow, and have geotextile fabric under liner; and
3. Removal of mud and sediment from the street or adjacent property(ies) immediately following such an occurrence; and
4. Conduct no land disturbing activity within 15 feet of the banks of streams, lakes, wetlands or other water courses or
water bodies; and
5. Provide adequate vegetative cover on any unstabilized areas to provide an effective barrier from erosion; and
6. Install any other measures as deemed necessary by representatives of the Erosion Control Division.
I understand that if the total disturbed area for any reason becomes greater than 20,000 square feet, including other lots I have under
construction within a common plan of development, a formal Erosion Control Plan will be required to be submitted and approved in order
to obtain a Grading/Erosion Control Permit. I further acknowledge that City Inspection's staff may refuse to make building inspections and
the Erosion Control Division may issue Notices of Violation, Stop Work Orders and/or Civil Penalty Assessments for failure to comply with
Erosion Control r irements. I also acknowledge that Grading/Erosion Control Permit fees will be doubled if work starts before obtaining
a permit e s require .
Signature Print Name J
Pr,*i T j - 1.3 — 20 23
Title Date Signed