NCC221137_FRO Submitted_20220323

City of Charlotte & Mecklenburg County
Soil Erosion and Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity covered by Chapter 17, Article 2 of the Charlotte City Code or
Section 6 of the Mecklenburg County Sedimentation and Erosion Control Ordinance prior to completing and filing this
form with the City of Charlotte Engineering and Property Management Department, Land Development Services Division
or Mecklenburg County Land Development Services. The financial responsibility party will be on record as the party to
accept any Notices of Violation or related documents for any non-compliance of the City of Charlotte Soil Erosion and
Sedimentation Ordinance. 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 Ridge Mixed -use Development
2. Address of land —disturbing activity:4840 Prosperity Church Rd; 4712 Prosperity Church Rd
3. Approximate date land -disturbing activity will commence: October 01 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Mixed-Use/Residential
5. Approximate acreage of land to be disturbed or uncovered: 35A
6. List total site acreage: 57.98
7. Landowners of Record (Use blank page to list additional owners): (4840 Prosperity
Name: Linda P. Smith and Stanley W. Smith, Co -Trustees under the Linda P. Smith Living Trust Church Rd)
Address: 4501 Johnston Oehler Rd, Charlotte, NC 28269
Telephone: S/5 4��C'C> Fax:
(Area Code) (;Area Code)
Email Address: ` i ��c�Gc>St3z c�
Signature:
Name: William G. Langley, Jr. ' Church Rd)
Address: 4712 Prosperity Church Rd, Charlotte, NC 28269
Telephone: 3 S"/ 3- Fax:
(Area Code) (Area Code)
Signature:
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 09982 Page 492 Book Page
Book 35872 Page 941
Book Page
Page 1

City of Charlotte & Mecklenburg County
Soil Erosion and Sedimentation
Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity covered by Chapter 17, Article 2 of the Charlotte City Code or
Section 6 of the Mecklenburg County Sedimentation and Erosion Control Ordinance prior to completing and filing this
form with the City of Charlotte Engineering and Property Management Department, Land Development Services Division
or Mecklenburg County Land Development Services. The financial responsibility party will be on record as the party to
accept any Notices of Violation or related documents for any non-compliance of the City of Charlotte Soil Erosion and
Sedimentation Ordinance. 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 Ridge Mixed -use Development
2. Address of land —disturbing activity: 5000 Prosperity Church Road; Parcel 02932133
3. Approximate date land -disturbing activity will commence:
October 01
2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential/Mixed-use
5. Approximate acreage of land to be disturbed or uncovered: 35.4
6. List total site acreage: 57.98
7. Landowners of Record (Use blank page to list additional owners):
Name: Gary L. Norris and Dean P. Norris
Address. 5000 Prosperity Church Rd, Charlotte, NC 28269
Telephone: cf� !2� 3_- ,Si/ s — Fax:
(Area Code)
Email Address:✓S?�G� /,�.f.��=i G►
Signature:
(Areas Code)
t [.r • Cv M
(5000 Prosperity
Church Rd)
Name: Christine J. Sylvester Trustee Under Stanley Walter Smith & Linda Plyler Smith irrev. Trust Agmt. (Parcel: 02932133)
Address: 4501 Johnston Oehler Rd, Charlotte, NC 28269
Telephone: A�X. 71 - Fax:
(Area Code) 11 (Area
Email Address:
S ignature:
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 5110 Page
Book 11680 Page
538 Book Page
293 Book Page
Page I

City of Charlotte & Mecklenburg County
Soil Erosion and Sedimentation
Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity covered by Chapter 17, Article 2 of the Charlotte City Code or
Section 6 of the Mecklenburg County Sedimentation and Erosion Control Ordinance prior to completing and filing this
form with the City of Charlotte Engineering and Property Management Department, Land Development Services Division
or Mecklenburg County Land Development Services. The financial responsibility party- will be on record as the party to
accept any Notices of Violation or related documents for any non-compliance of the City of Charlotte Soil Erosion and
Sedimentation Ordinance. 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 Ridge Mixed -use Development
2. Address of land —disturbing activity: 4503 Johnston Oehler Rd; 4501 Johnston Oehler Rd
3. Approximate date land -disturbing activity will commence: October 01 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential/Mixed-use
5. Approximate acreage of land to be disturbed or uncovered: 35.4
6. List total site acreage: 57.98
7. Landowners of Record (Use blank page to list additional owners):
Name: Stewart S. Smith (4503 Johnston Oehler Rd)
Address: 4505 Johnston Oehler Rd, Charlotte, NC 28269
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature: m__
Name: Linda P. Smith & Stanley /Y Smith Co -Trustees Under Linda P. Smith Living Trust (4501 Johnston Oehler Rd)
Address: 4501 Johnston Oehler Rd, Charlotte, NC 28269
Telephone: ��3• S✓ - cD Fax:
Email
Signati
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 1187 Page
Book 9982 Page
121 Book Page
492 Book Page
Page l

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Smith Farm NC LLC
Address: 474 Wando Park Blvd, Suite 205, Mt. Pleasant, SC 29464
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: H2 Contracting
Address: 731 McGilvary St, Fayetteville, NC 28301
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
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.)
Daniel Senden
Printed Name
Signature
Manager
Title
-7'? -vZ
Date
I lJ ijL ( �j- (U I t L ,(~T a Notary Public of the County
Of &VA V-i,C. S I a' , State of 70 C oLi A-;, o , hereby
certify that () AN( -•s Lr �E' N 0 6N personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notarial seal, this -7 4�, day of LR��T 20
Notary Signature:��L
My Commission expires: 1 -2- 2 c 2'6-
•
(MARMTTE-
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://landpermits.charmeck.org
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