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2. No person may initiate any land-disturbing activity on one or more acres as covered by the ordinance before this form and an acceptable erosion and sedimentation control plan have been completed and approved by the Rowan County Environmental Management Department.
4. Part A
5. Parcel ID Number
7. 1. Project Name*
9. 2. Location of land-disturbing activity (Highway/Street)*
11. Latitude
12. Longitude
14. 3. Approximate date land-disturbing activity will be commenced
    3. Approximate date land-disturbing activity will be commenced
16. 4. Purpose of development (residential, commercial, industrial, etc.)
18. 5. Approximate acreage of land to be disturbed or uncovered*
20. 6. Person to contact should sediment control issues arise during land-disturbing activity*

    *this information will be made available on the Rowan County Planning & Development website.

21. Cell Phone Number*
23. Email Address
25. 7. Landowner of Record
    Name
26. Landowner of Record
    Name
28. Current Mailing Address
29. Current Mailing Address
31. 8. Recorded in Deed Book Number
32. Page Number
34. Part B
36. 1. Person or Firm who are financially responsible for this land-disturbing activity
    Name of Person(s) or Firm(s)
37. Person or Firm who are financially responsible for this land-disturbing activity
    Name of Person(s) or Firm(s)
39. Current Mailing Address
40. Current Mailing Address
42. Phone Number
43. Phone Number
45. a. If the Financially Responsible Party is not a resident of North Carolina, give name and street address of a North Carolina Agent.
47. Name of Agent
48. Name of Agent
50. Current Mailing Address
51. Current Mailing Address
53. Phone Number
54. Phone Number
56. 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 the name and street address of the Registered Agent.
58. Name of Registered Agent
60. Current Mailing Address
61. Current Street Address
63. Telephone Number
64. Telephone Number
66. 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 authority to execute instruments for the Financially Responsible Person). I agree to provide correctional information should there be any change in the information provided herein.
68. Name
69. Title or Authority
71. Signature
72. Date
    Date
76. I, _________________________, a Notary Public of the County of _________________________ State of North Carolina, hereby certify that _________________________ appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him/her. Witness my hand and seal of Notary, this _____ day of _______________, 20__.
78. Notary
79. My commission expires
    My commission expires
81. Seal
83. Checklist
    Download a copy of the Erosion and Sedimentation Control Plan Checklist (PDF)
Leave This Blank:


84. Print Only

* indicates a required field