NCC223796_FRO Submitted_20221110

°"�'' Gaston County
Ey fk �F
I� Gaston Natural Resources Department
d 1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
Soil Erosion & Sedimentation Control
Financial Responsibility/Ownership
IN �
14
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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-
K
Project Name Carolina Riverside Offsite Force Main and Water Main
Location of land -disturbing activity
city of Belmont HighwaylStreet South Point Road
3. Approximate date land -disturbing activity will commence 10/01 /2022
4. Purpose of development (residential, commercial, industrial, etc.)
Linear Infrastructure
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 4.3E
fi. Amount of fee enclosed $ 1,500.00
7, Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s) of Record (Use blank page to list additional owners)
iJ
10
BELMONT #2 US 321 BYPASS
Name
2820 SELWYN AVE STE 500
Mailing Address
CHARLOTTE, NC 28209-1791
City State Zip
Telephone Number
Gaston County Board of Education
Name
943 OSCEOLA ST
Mailing Address
GASTONIA, NC 28054-5482
City State Zip
Telephone Number
Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book 4375 Page 0572
Deed Book 4928 Page 0800
Tax Map No. 201480 & 216910
Block NIA Lot No. NIA
Page I

PART B:
1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity
Pulte Home Company, LLC
Name
11121 Carmel Commons Blvd. Suite 450
Mailing Address
Charlotte, NC 28226
City State Zip
[phone]
Telephone Number
Name
Mailing Address
City State Zip
Telephone Number
If the Financially Responsible Party is not a resident of North Carolina, give name and street
[luul CZ�J V1 C! IrLA ll1 01 Li 1110 CILJUF 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
0%J11 ti JOIJ� provided by me under oath. (This form must be signed by the financially responsible person if an
%
ind
vidual or
s attorney -in -fact, or, if not an
�'`5e is h°�'�e •��o, registered eyed agent with authority to execute instruments idforlthe financially responsible person). , by an officer, director, partner, of
��:•yy"pf,''• ;agree to provide corrected information should there be any change in the information provided
0 0~tPRY N0 O'&reln.
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;� Pub,, ti _'�;.Oeremy Huntsman
02 �3.ype or Print Name
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`�. �enbUr� ,• = .ram--- •- .
���►�111100% 4:'Siignature ~ - --
Director of Land Development
Title or Authority
Date
I, , a Notary Public of the County of L , State of North
CafoVn a, hereby certify that a ppea re6 personally be re me this day
and being duly sworn acknowledged that t e bove form was executed by him.
Witness my hand and notarial seal, this y, day of 75a2�7� .
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Nlp SEAL 4y Commissioli Expires
Fife: Financial Responsibility -ownership Form.rnw
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