NCC230022_FRO Submitted_20230104

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Gaston County
Gaston Natural Resources Department
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1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
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Soil Erosion & Sedimentation Control
d Financial Responsibility/Ownership
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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
aDDroved by the Gaston County Natural Resources Department's staff.
type or print and, if question is not applicable, place N/A in blank)
PART A:
1. Project Name
2. LocatiAAn of land -disturbing activity ��
City (5�ts oni tit Highway/Street e4 W 00
3. Approximate date land -disturbing activity will commence o?I b ec 2bZZ
4. Purpose of development (residential, commercial, industrial, etc.) r16yd 141.r
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 4.2 aapj
6. Amount of fee enclosed $
7. Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s) of Record (Use blank page to list additional owners)
9
We
Name "
12 W R f ch e
Mailing Address
Od land Nc a8/o7
City State Zip
9Xo zAJ? gYp2-
Telephone Number
Name
Mailing Address
City State Zip
Telephone Number
Indicate Deed Boo and Page where deed(s)or ins trument(s) are recorded
Deed Book Page
Deed Book Page
Tax Map No. 1390
Block /Vlf(4 WE
Lot No. _ 9 4-
Page I

PART B:
1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity
Name "
l zcI b7 t"Z, ct f e
Mailin Address
/V114 pea fU G �t$/a7
City State Zip
980 25:7' 91YO-1-
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
aooress of a Norm uaroiina
Name
Mailing Address Street Address
City State Zip Telephone Number
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 attomey-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.
"Doodd lbucho h- ----
Wgnature�
int Name
AdM1 o is�ra� ion /Yj_r,�
Title or Authority
Date
6C C 2 022--
I, Nba lkiA C(ZU , a Notary Public of the County of 7(N I U(\ State of North
Carolina, hereby certify that U or-%CAjCA A,NUQr%013 appeared personally before me this day
and being duly sworn acknowledged that the above form was executed by him.
Witnes y hand :V.1
rial seal, this ,3, � 1,day, of S)�.S__,
GRUZ -t .r
E Y �� wVy Commission Expires
(P` File: Financial Responsibility -Ownership Form.mw
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