NCC221155_FRO Submitted_20220324

°"'�`� Gaston County
Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
U814 Soil Erosion & Sedimentation Control
Q
Financial Responsibility/Ownership
No person may initiate any land -disturbing activity on one (1) or more acres of property in all portions of
Gaston County, except for that property within the city limits of the incorporated municipalities of Gaston
County who have not adopted the Gaston County Soil Erosion & Sedimentation Control Ordinance,
before this form and an acceptable Soil Erosion & Sedimentation Control Plan have been completed and
approved by the Gaston County Natural Resources Department's staff.
(Please type or print and, if question is not applicable, place N/A in blank)
PART A:
1. Project Name McAdenville lots 53-60
2. Location of land -disturbing activity
city McAdenville, NC Highway/Street, Lakeview Drive
3. Approximate date land -disturbing activity will commence 3/1/22
4. Purpose of development (residential, commercial, industrial, etc.) Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 1.6 ac
6. Amount of fee enclosed $ 600
7. Soil Erosion & Sedimentation Plan Filed? Yes x No
8. Landowner(s) of Record (Use blank page to list additional owners)
Name
Mailing Address
City State Zip
Telephone Number
Name
Mailing Address
City State Zip
Telephone Number
9. Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book_ Page
Deed Book Page
10. Tax Map No. 223208 - 223215, 219301 Block Lot No.
Page 1

PART B:
1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity
Evans Coghill Homes II, LLC
Name
4108 Park Road Suite 413
Mailing Address
Charlotte NC 982og
City State Zip
704-334-6789
Telephone Number
Name
Mailing Address
City State Zip
Telephone Number
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street
dUU1 CJJ ul a IVUIUI Udl ulll Id dqui IL.
3. 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 Part is a Corporation give name and street address of the Registered Agent.
Name
Mailing Address Street Address
City State Zip Telephone Number
4. 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 corrected information should there be any change in the information provided
herein.
Alan C. Banks Managing Membec
Type or Pri Nam Title or Authori
?_ I'l �?,z
Signatur Date
��4a N ary P lic f the County of State of North
Carolina, hereby certify that �. appeared personally fore me this day
and being duly sworn acknowle ed tha t hove for execu d by him.
Witness d nd norl�L�NTSIIL
day of 20 .
�,- 04
Y
Notary riolajc My Cf mmiss's Expires
Mack(enburg Co., North Carolina File: Financial Responsibility -Ownership Form.mw
My commission Expires Dec. 27, 2026
Page 2