NCC223392_FRO Submitted_20220929

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
+� SEDIMENTATION POLLUTION CONTROL ACT
�L-
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 N/A in the blank.)
Part A.
1. Project Name Riverwood Ranch Phases 1 &2
2
3
4
5
Location of land -disturbing activity: County JOHNSTON City or Township CLAYTON
Highway/Street Pritchard Road Latitude 35.6945 Longitude-78.4213
Approximate date land -disturbing activity will commence: September 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 47.21
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 Nick MCKeel E-mail Address [e-mail]
Telephone [phone]
Cell #
Fax #
8. Landowner(s) of Record (attach accompanied page to list additional owners):
Riverwood Ranch, LLC 919-901-3178
Name Telephone
114 W Main Street Same
Current Mailing Address
Clayton NC
City State
9. Deed Book No. 06148
Part B.
Current Street Address
27520 Same
Zip City
Page No. 0890
Fax Number
State
Zip
Provide a copy of the most current deed.
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.
Riverwood Ranch LLC
Name
114 W Main Street
[e-mail]
E-mail Address
Same
Current Mailing Address Current Street Address
Clayton NC 27520 Same
City State
Telephone [phone]
Zip City State Zip
Fax Number

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:
Current Mailing Address
City State Zip
E-mail Address
Current Street Address
City
Telephone Fax Number
State Zip
(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
Current Mailing Address
City
state Zip
E-mail Address
Current Street Address
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.
Reid Smith Managing Member
Type or print name Title or Authority
2/28/2022
Date
1, -,et"r CA. t.. MDUV1 2 , a Notary Public of the County of WOW. t,
State of North Carolina, hereby certify that `31nn 'OiA ,_ appeared
personally before me this day and being duly swom acknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this ?, *" day of -k rw owq 20
M
Seal �p.�piiY ? Notary
' My commission expires