NCC223796_FRO Submitted (2)_20221110

Gaston County
Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
C'
t� Stormwater
sa4 pA
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 Stormwater Ordinance, before this form and an
acceptable Stormwater 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 Carolina Riverside Offsite Force Main and Water Line
2. Location of land -disturbing activity
City of Belmont Highway/Street 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) 4.36
6. Amount of fee enclosed $ 1,750.00
7. Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s) of Record (Use blank page to list additional owners)
9
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
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71:i1i:3
Person(s) or firm(s) who are financially responsible for this property.
Pulte Home Comoany, LLC
Name
11121 Carmel Commons Blvd. Suite 450
Mailing Address
Charlotte. N
City State Zip
(704) 72- 752
Telephone Number
Jeremy Huntsman
Contact Name for Inspection Reports
[e-mail]
Email Address
�4) 972-0752
Telephone Number
Fax Number
If the Financially Responsible Party is not a resident of North Carolina, give name and street
address of a North Carolina agent.
N/A
Name
Mailing Address Street Address
City 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 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
••��������trir����� individual or his attorney -in -fact, or, if not an individual, by an officer. director. partner, or
��•` Sean rhpr fr,� registered agent with authority to execute instruments for the financially responsible person). I
`t` = 'iasior� '•• �7
�0 .:fib E+�.,co :�igree to provide corrected information should there be any change in the information provided
m v° �Af 1lprein.
a U Seremy Huntsman : z-
• - -
iJBL��, Za;' .�Type or Print Name
9 �-
Director of Land Development
Title or Authority
Date
I,rtt� , a Notary Public of the County of Y1 Slate of North
CPt4ina, hereby certify that ']s Tt OAM IN appeareJ personally befate me this day
and being duly sworn acknowledged that he above form was executed by him.
Witness my hand and notarial seal, this IS day of -J'21LZ2..
!�e-_ YU I3 , Z 021
N t SEAL Mj Commission 4xpires
File: Financial Responsibility -Ownership Form-mw
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