NCC220884_FRO Submitted_20220224

FINANCIAL RESPONSIBILITY AND OWNERSHIP FORM
HAYWOOD COUNTY CODE OF ORDINANCES, CHAPTER 154 EROSION AND SEDIMENT CONTROL; and,
CHAPTER 158, SLOPE ORDINANCE
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No person may initiate a land -disturbing activity on one-half or more acres as covered by Chapter 154 before this form and an acceptable erosion
and sedimentation control plan have been completed and approved by the Haywood County Erosion Control Program. (Please type or print, and if
question is not applicable, place NIA in the blank.). This form also addresses artificial (i.e. cut or fill) slope construction and repair as covered by
Chapter 158. No Certificate of Occupancy will be issued and no final subdivision plat approved until the Erosion Control Office has received a
completed affidavit from the person financially responsible that the project site is in compliance with the Haywood County Slope Ordinance.
ECTION A.
1. Project Name: Crabtree Mountain Road Campground (Phase 2)
2. Property Identification Number or Deed BooklPage: 8659-1 1-3161
3. Address of land -disturbing activity: 2504 Crabtree Mountain Road
4. Starting date for land -disturbing activity: August 2021
5. Purpose of this activity: ❑Residential requiring a Certificate of Occupancy, ❑Minor Subdivision, ❑Major Subdivision,
❑Commercial or Industrial requiring a Certificate of Occupancy, ®other: Campground Development
6. Total acreage disturbed or uncovered (including off -site borrow or waste areas): 3.45
7. Fee enclosed: $ 1,400.00 , Bond amount: $ .,Type of Security:
8. Has an erosion and sedimentation control plan been filed?,
9.1 will notify Haywood County Erosion Control within days of when grading equipment is moved off the site.
10. Person to contact should sediment control or slope construction issues arise during land -disturbing activity:
Matt Bare Telephone Numbers: [phone]
11. Landowner of Record (List all owners):
Name(s): f' a ff 04,VM-. % er{
Mailing Address ��r% _ �S l•"+s ��c4.J /%r !!f��e..7�� Sr R44/
Telephone Numbers: It/3 61:7!Z'• .ZX 2 „_
Fax Number. , E-mal' rrc l�, b"'r Zev'd9
12. Person or firm financially responsible for this land -disturbing activity and compliance with the Slope Ordinance:
Name: Matt Bare
Mailing Address: 674 Fishermans Bend Mt Pleasant SC 29464
Telephone Numbers: 843-475-2962
Fax Number: , E-mail: matt•[e-mail]
13. My land -disturbing operator/contractor information is:
Randv Best
Mailing Address:
Telephone Numbers: 828-421-6017
Rev. 8-24-12

Financial Responsibility and Ownership Form
(Land -Disturbing Activities)
Page 2 of 3 M g
Initials of Financially Responsible Person
14. My Building Contractor information is:
Mailing Address:
Telephone N
15. If the Financially Responsible Person is not a resident of North Carolina, give name and street address of a North
Carolina Agent:
David Hutnik
Mailing Address:
Street Address: 112 Pine St Shalotte, NC 28470
Telephone Numbers: 910-363-7776
Fax Number:
E-mail: [e-mail]
16. If the Financially Responsible Person 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 Person is a corporation, give name
and street address of the Registered Agent.
Name:
Mailing Address:
Street Address:
Telephone Numbers:
Fax Number: , E-mail:
SECTION B. ARTIFICIAL SLOPE REQUIREMENTS FOR ALL PROJECTS.
1- RrYes, ❑No -)o 1 understand that my project must comply with Chapter 158: Slope Ordinance of the Haywood County Code of
Ordinances before a Certificate of Occupancy can be issued.
2- 0Yes, I]No 41 understand that all fill slopes must be compacted in accordance with the Standard Operating Procedure for
compaction. (You may request a copy of the Standard Operating Procedures or view them on the Erosion
Control's webpage)
3- ❑Yes, BdNo 4Does this project have any cut slopes steeper than 1:1 (horizontal: vertical) or fill slopes steeper than 1.5:1 (h:v)
and greater than fifteen feet (16) in vertical height? (Slope Plan is required, contact Erosion Control Office)
4- 2Yes, ❑No 4Do all proposed artificial slopes meet the setback requirements in accordance with the Standard Operating
Procedures? **(The toe of a constructed fill slope and the top of a constructed cut slope cannot be within five feet
(5') of a property line.
5- ®Yes, ❑No ->Will any artificial slope be taller than 40 feet (vertical) and steeper than 1:1 (cut) or 1.5:1 (fill)? (Variance is
required, contact the Erosion Control Office)
6- ®Yes, ❑No 41 will provide stabilized ditches or other methods to prevent uncontrolled stormwater runoff from going over
artificially constructed or repaired slopes.
7- ❑Yes, ®No 4Will an offsite borrow source be used for fill slope construction or repair? If yes, provide the location(s) of the
source (PIN, DBIPG, or address)
Rev. 8-24-12

Financial Responsibility and Ownership Form
(Land -Disturbing Activities)
Page 3of3 MB
Initials of Financially Responsible Person
SECTION C. ARTIFICIAL SLOPE REQUIREMENTS FOR MINOR AND MAJOR SUBDIVISIONS ONLY:
1- EZYes, ❑No 4 My development activity is a MINOR SUBDIVISION or a MAJOR SUBDIVISION. I understand that subdivision
plats will not be approved or recorded until all subdivision roads are completed and field verified for compliance
with the Slope Ordinance.
2- ®Yes, ❑No 3 1 understand that I must provide the Erosion Control Office with Standard Proctor test data in accordance with
§158.10(A) of the Slope Ordinance on all proposed fill soils forming artificial slopes.
3- RYes, ONO 41 understand I must provide the Erosion Control Office with copies of the final engineering certifications that are
provided to the State regarding the construction and testing of public WATER and SEWER lines anytime said
utility lines are located in a fill slope. I further understand that the person financially responsible for the slope work
shall provide copies of the final engineering certifications within 30 calendar days of completion of the work.
THE FOLLOWING NOTARIZED STATEMENT MUST BE COMPLETED FOR ANY AND ALL SECTIONS OF THIS DOCUMENT.
(This form must be signed by the Financially Responsible Person, if an individual, or by his or her attorney -in -fact. If the Financially
Responsible Person is not an individual, this form must be signed by an officer, director, partner or registered agent with the
authority to execute instruments for the Financially Responsible Person.)
I agree to conduct all land -disturbing activity on the subject property in accordance with the information provided herein
and the Haywood County Code of Ordinances. I understand and acknowledge that Haywood County assumes no liability
for the design or adequacy of this plan or the work resultant from the approval of this plan, and I now and hereafter hold
harmless and indemnify Haywood County for all grading activities for which I am responsible. I have received, if
requested, a copy of the applicable Haywood County ordinances. I agree to provide corrected information should there be
any change in the information provided herein. All information I have provided in this form of Financial Responsibility and
Ownership is true and correct to the best of my knowledge. I understand that failure to comply with the Erosion and
Sediment Control Ordinance or the Slope Ordinancq,*ay result in the assessment of civil penalties.
Person Financially Responsible:
Matt Bare
Land Owner:
(Signature)
(Print Name)
I ev-r-SM W D41! C. VZ r a Notary Public of the County of 146twW Ood
In the State of N nV -�k M r( K CL , do hereby certify that mocif sare
personally appeared before me this
day and acknowledged the due execution of the foregoing instrument. -�- r
Witness my hand and Official Seal this day of �_ Jet, tL., .20 02 1
Notary:
Teresa er
Notary Public My commission expires.
Haywood County
North Carolina
M Commission Expires
Rev. 8-24.12

AFFIDAVIT FOR LAND -DISTURBING ACTIVITIES IN HAYWOOD COUNTY, N. C.
(Statement of Intent and Commitment to Perform by the Person Financially Responsible
andlor by the Land Owner)
PROJECT: Crabtree Mountain Road Campground (Phase 2) PIN # 8659-11-3161
LOCATION: 2504 Crabtree Mountain Road
I now state under oath that I will perform all land -disturbing activity on this project, for which I am responsible or upon
land I own, in accordance with the provisions of Chapter 154 of the Haywood County Code of Ordinances and within
the obligations set forth in this performance obligation and in my erosion and sediment control plan as approved by
Haywood County. i acknowledge that Haywood County's Erosion and Sediment Control Ordinance is based on rules
and regulations promulgated by the State of North Carolina in the Sedimentation Pollution Control Act of 1973 (as
amended) and in the North Carolina Administrative Code.
►I have received a copy of the Haywood County Erosion and Sediment Control Ordinance.
►I will comply with the provisions for establishing temporary and permanent ground covers as per the Ordinance.
Some requirements are as follows: The angle for graded slopes and fills shall be no greater than the angle
which can be retained by vegetative cover or other adequate erosion control devices or structures. In any
event, slopes left exposed will, within 21 calendar days of completion of any phase of grading, be planted or
otherwise provided with a temporary or permanent ground cover, device, or structure sufficient to restrain
erosion.
a) If any graded slopes or fills on this project are to be left idle for a period of twenty one (21) calendar
days, I agree to seed and mulch these disturbed areas by the seventh (71") calendar day. I realize that
this will give disturbed areas two weeks for the grass to grow. if these disturbed areas are not
adequately protected by day twenty one (21) or if any graded slopes or fills on this project are not
planned for vegetative cover, I will provide other adequate ground covers on all the applicable
disturbed areas by the end of day 21. 1 realize that these types of ground covers include gravel,
adequate mulch, rip rap with filter cloth, sod or other measures that will meet the requirements of the
Ordinance to restrain erosion.
b) If my construction is in a season of the year considered outside the window for successfully
establishing vegetative ground cover (when frost normally occurs), I will comply by using other
acceptable applications of material such as adequate mulch to meet the requirements of the ground
cover requirements.
c) I understand that open channels such as ditches may be difficult to stabilize with grass ground
cover. I may meet this ground cover obligation by using either check dams to help grass establish,
sod in the ditch, or hardened liners such as rock rip rap or fabric liners. I will construct adequately
sized ditches, and I will stabilize them as per the requirements of the Ordinance.
0-1 will install all reasonable measures to protect all public and private properties from any sediment damage as a
result of my land disturbing activity. I will keep my sediment on my property by using a combination of the following
acceptable erosion and sediment control practices: o gravel construction entrance, ❑ trenched, tamped and
adequately braced silt fence, ❑ silt pits, ❑ sediment traps, ❑ diversion ditches, ❑ berms, ❑ measures to keep sediment
out of culverts.
► 1 or my designate(s) will inspect all erosion and sediment control measures at least once every seven (7) calendar
days and after any rain event producing 0.5 inches or more precipitation during any 24-hour period. I am the person
responsible for cleanout and maintenance of erosion and sediment control measures on my project. I know that
maintenance is my responsibility even though I may hire someone else to perform the work. I will maintain the
measures on my property or project and keep them functional and adequate.
► 1 am now informed that the average yearly rainfall for Haywood County is 50" to 60" of rain (distributed from north
to south). I am now informed that the amount of rainfall from the 24-hour, one-year storm is 3" to 3.5" of rain, and the
24-hour, ten-year storm produces from 5" to 6" of rainfall (distributed from north to south).
Rev. 8-24-12 Page 1 of 2

►I am aware of the rules and regulations regarding buffer zone requirements as per the Ordinance; and some are as
follows (the Ordinance contains the complete listing of requirements):
a) No land -disturbing activity during periods of construction or improvement to land shall be permitted in
proximity to a lake or natural watercourse unless a buffer zone is provided along the margin of the
watercourse of sufficient width to confine visible siltation within the 25% of the buffer zone nearest the land -
disturbing activity.
b) Waters that have been classified as trout waters by the Environmental Management Commission shall have
an undisturbed buffer zone 25-feet wide or of sufficient width to confine visible siltation within the 25% of the
buffer zone nearest the land -disturbing activity, whichever is greater. Provided, however, that the Director
may approve plans which include land -disturbing activity along trout waters when the duration of the
disturbance would be temporary and the extent of the disturbance would be minimal. This subdivision shall
not apply to a land -disturbing activity in connection with the construction of facilities to be located on, over, or
under a lake or natural watercourse.
c) Unless otherwise provided, the width of a buffer zone is measured from the edge of the water to the nearest
edge of the disturbed area with the 25% of the strip nearer the land -disturbing activity containing natural or
artificial means of confining visible siltation.
d) The 25-foot minimum width for an undisturbed buffer zone adjacent to designated trout waters shall be
measured horizontally from the top of the bank.
e) Where a temporary and minimal disturbance is permitted as an exception by G.S. §113A-57(1) land -
disturbing activities in the buffer zone adjacent to designated trout waters shall be limited to a maximum of
10% of the total length of the buffer zone within the tract to be distributed such that there is not more than
100 linear feet of disturbance in each 1000 linear feet of buffer zone. Larger areas may be disturbed with the
written approval of the Director.
)-As per §154.60(C)(6)(a) of the Erosion Control Ordinance, the specific time frame I am requesting for this land -
disturbing activity is (from the commencement of land -disturbing activity to the point of final stabilization):
Gp` o 21 U 5 09 i ZZ 7ese-
TCommencement dater T Ending Date T T Amount of time requested T
► I agree to comply with the provisions of my erosion and sediment control plan as approved or modified by
Haywood County, the above statements and the rules, regulations, and requirements of Chapter 154 of the Haywood
County Code of Ordinances: Erosion and Sediment -Control. Witness my signature below:
Person Financially Responsible:
Land Owner:
1, 1 Ct-rmSq w D2a vkr- a Notary Public of the County of �aUlllf DL5 cA
in the State of W C*-JC'w'%— C&M i,l VL& hereby certify that
personally appeared before me this day and acknowledged the due
execution of the foregoing instrument.
Witness my hand and Official Seal this oZ. day of 20 o2
Teresa WDesver Notary:
Notary PublicCounty
0�5 oZl�
iHao C County M commission expires: North Carotina � � Y p
M Commission ires
Rev. 8-24-12 Page 2 of 2