NCC221655_FRO Submitted_20220428

M ` ° Mecklenburg County Soil Erosion and
` Sedimentation Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity covered by Section 6 of the Mecklenburg
County, Mint Hill or Davidson Sedimentation and Erosion Control Ordinances prior to
completing and filing this form with Mecklenburg County Land Use and Environmental
Services. The financially responsible party will be on record as the party to accept any Notices
of Violation or related documents for any non-compliance with the above Ordinances. If the
financially responsible party is out of State, a North Carolina agent must be assigned.
Please Type or Print
PART A
1. Project where land -disturbing activity is to be undertaken: Prosperity- a mixed use facility.
2. Address of land -disturbing activity: 12404 Summer Creek Lane
Charlotte, NC 28269
3. Approximate date land -disturbing activity will commence: 4/25/2022
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): Residential & Commercial
5. Approximate acreage of land to be disturbed or uncovered: 5 A.
6. Total site acreage: 5.18 A.
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: Wagener Properties Charlotte, LLC
Address: 14590 Dory Lane
Fort Myers, FL 33908
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner #2 Name: Halcyon Land, LLC.
Address: P.O. Bopx 21439
Bradenton, FL 34204
Telephone: [phone]
Email Address: [e-mail]
Fax:
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 24351 page 052
Book 35494 page 968
Book Page
Book Page
Form Revised 12-2016
(continue on back or separate pages as necessary)

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: The Greenstone Group, LLC
Address: 14590 Dory Lane, Fort Myers, FL 33908
Telephone: [phone]
Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Harry Marsh Law, pIIC
Address: 10550 Independence Point PKWY, Suite 302, Matthews, NC 28105
Telephone:
704-743-6387
Email Address:
Fax:
3. The above information is true and correct to the best of my knowledge and belief and was
provided by me while under oath. (This form must be signed by the financially responsible
person if an individual or by an officer, director, partner, attorney -in -fact, or other person
with authority to execute instruments for the financially responsible company or entity, if not
an individual.)
John H. Wagener
Member/Manager
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Date
1, (/ -jL�'-t ° CCnVt-- ma-Cj�0L'LC44 L 1 , a Notary Public of the
County of G-2e State of RDr � da_ , hereby
certify that jahn f f (j q q-r_ l.G/ personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial seal, thiso day of� , 20 2-
Notary Signature:
My Commission expires: °, (202X-
MY COMMISSION # GG 247264
Bonded Thru Notary Public Underwritors
Mecklenburg County Land Use and Environmental Services Agency
2145 Suttle Ave.
Charlotte, NC 28208-5237
Phone [phone]