NCC220864_FRO Submitted_20220223

Soil Erosion and Sedimentation Control
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�+ 4114 F 14 l A Yl la Y i x A Financial l esponsibility/ wnership Farm
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NOT REQUIRED TO BE C'OAfPL.E7ED FOR RE.SID NTIAL LOT PERMITS.
PLEAS E READ THE FOL L0WN INFORMATION
) This section must be signed in the presence o1'a Notary _
2) All Land -Disturbing permits are valid for up to (2) years from the data of issuance- If 6rcumOances warrant, the permit may be
extended For (2) years per the conditions of the Chatham County Soil Erosion and Sedimentatiorn Control Ordinance. Upon written
notice, the Land -Disturbing permit ruay be revoked For Failure to comply with the Ordinance- If the permit is revolted, a]I other
permits and approvals are withheld until the property is once again in compliance with Chatham County regulations. Also, upon
written notice, a civil penalty (fine) can be instigated against the property owner andJor additional finan6ally responsible parry (if any)
for violations of the Chatham County Soil Erosion and Sedimentation Control Ordinance. This penalty is up to $5000.00 per violation
per day and is assessed daily For every day the property is in violation. Interfering with or hampering are inspection can result in a civil
penalty without written notice.
3) The information provided on this form is true and correct to the best of my knowledge and belief and was provided by me while
under oath.
4) `Phis fore, mutt be signed by the property owner if an individual. 1f owned by a company or corporation, this form must be signed
by an officer, director, partner, attorney -in -fact, or other person with authority to execute instruments for the corporation and
accompanied by a complete list of all p7 irtnefs, managing members and rcgistWred agents of the company or corporation -
OWNER OF PROPERTY.
Name and `title;
Company (if applicable):
Signature:
ADDITIONAL R AN IALLY RESPONSIBLE PARTY orany):
Name and Title:
Company-
Signature -
NORTH CAROLINA AGENT {if any}:
Name and Title,
Company:
Signature;
IfllnL a Notary Public of -.__-. County in the state
of do hereby certify that +� � 1�z personally
appeared before me this day and under oath acknowledged reading the information above and acknowledged that the
above form was executed by him or her.
Witness mar hand and official seal, this the day of�'C.ytc~ , 20 1.
. �% NON
1 ��nlssrayj
Notary public w tT9�
My comin is inn expires A,3j161, (S
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