NCC216720_FRO Submitted_20211203

Gaston County
� Jf Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
Soil Erosion & Sedimentation Control
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:
2.
Project Name Brandon Creek Subdivision
Location of land -disturbing activity
City Gaston County _ _ Highway/Street Forbes Road
3. Approximate date land -disturbing activity will commence January 2022
4.
5.
6.
Purpose of development (residential, commercial, industrial, etc.) Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas) 121 ac
Amount of fee enclosed $36,300
7. Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s) of Record (Use blank page to list additional owners)
0
10.
Name
Name
Mailing Address *SEE ATTACHED SHEET FOR PROPERTY INFORMATION*
City State Zip J I City
Telephone Number
Telephone Number
State Zip
Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book pane
Deed Book *SEE ATTACHED SHEET FOR
PROPERTY INFORMATION*
Tax Map No. Lot No.
Page 1

PART B:
1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity
George Bartley Carroll (D.R. Horton, Inc.)
Name
8025 Arrowridge Blvd
Mailing Address
Charlotte NC 28273
City State Zip
704-620-7373
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
CA I V00 vi a i MI I at V Ito slum I
CT Corp
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.
afar�A &i-f ', &"r.' IVpOFS141an.-cl'
Type or 11rint Name Title or Authority
O —12- Z ZO Z
ignature Date
I, Rat,.ekej ilia✓ `yj 4&U,*S_, a Notary Public of the County of _da_&]byti , State of North
Carolina, hereby certify that C►;--,A- Bav4�ku Carr-p 11 appeared personally before me this day
and being duly sworn acknowledged that the ab ve form was executed by him.
Witness my hand and notarial seal, this 10 day of u 4 , 2 b Z 1 .
27 2.025
Notary SEAL My Com ission Expires
Rachel Martin Hayes File: Financial Responsibility -Ownership Form.mw
NOTARY PUBLIC
Gaston County
North Carolina Page 2
My Commission Expires May 27, 2025

HIGHWAY 321 FORBES RD LLC 93% &
DURBORAW IRREV TRUST 6.66%
C/O SOUTHEAST LAND MGT, LLC 2820
2820 SELWYN AVE STE 500
CHARLOTTE, NC 28209
DB: 4033
PG: 2499
TAX PARCEL NO.: 146376
2. HIGHWAY 321 FORBES RD LLC 93% &
DURBORAW IRREV TRUST 6.66%
C/O SOUTHEAST LAND MGT, LLC 2820
2820 SELWYN AVE STE 500
CHARLOTTE, NC 28209
DB: 4134
PG: 0020
TAX PARCEL NO.: 146377
3. HIGHWAY 321 FORBES RD LLC 93% &
DURBORAW IRREV TRUST 6.66%
C/O SOUTHEAST LAND MGT, LLC 2820
2820 SELWYN AVE STE 500
CHARLOTTE, NC 28209
DB: 4133
PG: 2499
TAX PARCEL NO.: 147284
4. HIGHWAY 321 FORBES RD LLC 93% &
DURBORAW IRREV TRUST 6.66%
C/O SOUTHEAST LAND MGT, LLC 2820
2820 SELWYN AVE STE 500
CHARLOTTE, NC 28209
DB: 4133
PG: 2499
TAX PARCEL NO.: 147285