NCC223511_FRO Submitted_20221011

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity that disturbs 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. Lots smaller than one
acre that are part of a larger plan of development are also subject to Town of Clayton Soil Erosion and
Sedimentation Control Ordinance and are required to complete this form. (Please type or print and, if the
question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
1. Project Name Walton Farm Ph 5-6
2. Location of land -disturbing activity: County JOHNSTON City or Township CLAYTON
Highway/Street
Covered Wide R=Iuh ConnecUan BlvdLatitude -78.42008 Longikude 35.68147
3. Approximate date land -disturbing activity will commence: October 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 14.68 ac
6. Has an erosion and sediment control plan been filed? Yes _ No Enclosed
7. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name N ick MCKeel E-mail Address nick.mckeel@providence. construction
Telephone [phone] cell # nla Fax # n/a
8. Landowner(s) of Record (attach accompanied page to list additional owners):
Walton Farms, LLC nla nla
Name Telephone Fax Number
400 Riverwood Drive same
Current Mailing Address Current Street Address
Clayton NC 27527 same same same
City State Zip City State Zip
9. Deed Book No. 5403 Page No. 74-79 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.
Walton Farms, LLC
Name
400 Riverwood Drive
Current Mailing Address
Clayton NC 27527
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
same
Current Street Address
same same same
City State Zip
Fax Number n.a

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.
Fred Smith Managing Member
Type or�rint name Title or Authority
�nJs12Z
Signature Date
I, k1OP1_CCn (, • 11i 81LIVI / , a Notary Public of the County of WQLU
State of North Carolina, hereby certify that 1V_eA Corn dL4 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 4 ' day of & b)OtY , 20. 23: -
GGP L M
�pTARY N
Seal r Wi 60,665
sit
sy4 P1V81-O
T Ono tr-.4