NCC222844_FRO Submitted_20220818

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Gaston County
Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NG 28034 'relephone: 704-922-4181
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 NIA in blank)
PART A:
1. Project Name Catawba Cove Subdivision
2. Location of land -disturbing activity
City Belmont NC Highway/Street Catawba Cove Road SR#2650
3. Approximate date land -disturbing activity will commence August 2020
4. Purpose of development (residential, commercial, industrial, etc.) R e sid e n tial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 6.89 Ac
6. Amount of fee enclosed $ 2400.00
7. Soil Erosion & Sedimentation Plan Filed? Yes X No
8, Landowner(s) of Record (Use blank page to list additional owners)
E
10.
Catawba Rivert Investmenir. LC
Name
1031 S Caldwoll Stroot Suito 220
Mailing Address
Charlotte NC 28203
City State Zip
[phone]
Telephone Number
Name
Mailing Address
City State Zip
Telephone Number
Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book 4999 Page 2215
Deed Book Page
Tax Map No. 201265 Block Lot No. _
Page I

PART B:
1. Person(s) or firm(s) who are financially responsible for this land -di 3turbing activity
Catawba Riverp Investment; LLC (Keith Glenn)
Name
1031 S Caidwell Street, Suite 220
Mailing Address
Charlotte NC 23203
City State Zip
704 527-0204
Telephone Number
NIA
Name
Name
Mailing Address
City
Telephone Number
State Zip
If the Financially Responsible Party is not a resident of North Carolina, give name and street
address of a North Carolina agent,
Mailing Address Street Address
city
NIA
Name
State Zip
telephone Number
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 assuried name If the Financially
Responsible Part is a Corporation give name and street address cf the Registered Agent,
Mailing Address Street Address
City State Zip Telephone Number
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 a n 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.
(21
Type or Print Name
Signature
Title or Authority
:Z/ L-�
Date
a Notary Public of the County of 14 �e' State of North
Carolin , hereby cetft that appeared personally before me this day
and being duly sworn acknowledged that the above form_was executed by hirn.
ig-s-s my hand and notarial seal, this _ '` day of t�I h, 2 +
Notary:`� My Gommiasion Expires
File: Finan--ial Responsibility -Ownership Form.mw
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