NCC231350_FRO Submitted_20230508

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Mecklenburg County Soil Erosion and
:to Sedimentation Control Ordinance
°MTh �A�o�r Financial Responsibility/Ownership Form
No person shall initiate any land-disturbing activity covered by Section 6 of the Mecklenburg
County, Mint Hill or Davidson Sedimentation and Erosion Control Ordinances prior to
completing and filing this form with Mecklenburg County Land Use and Environmental
Services. The financially responsible party will be on record as the party to accept any Notices
of Violation or related documents for any non-compliance with the above Ordinances. 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: Cheval Lot 90
2. Address of land-disturbing activity: 6203 Hollow Oak Dr., Mint Hill, NC 28227
3. Approximate date land-disturbing activity will commence: 05 15 2023
Month Day Year
4. Purpose of development(Residential, Commercial, Industrial, etc.): SF Residential House
5. Approximate acreage of land to be disturbed or uncovered: 0.723
6. Total site acreage: 0.93
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner#1 Name: Ashleigh Brooke Sides
Address: 46073 Hall Road
Sterling, VA 20166
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner#2 Name:
Address:
Telephone: Fax:
Email Address:
8. Indicate Book and Page where the deed or instrument is filed(use blank pages to list
additional deeds or instruments as necessary):
Book 35816 Page 419 Book Page
Book Page Book Page
(continue on back or separate pages as necessary)
Form Revised 12-2016

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s)or firm(s) financially responsible for this land-disturbing activity:
Person or Firm: Custom Homes of the Carolinas, Inc.
Address: 8365 Reed Mine Road
Midland, NC 28107
Telephone: [phone] Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Donna Wildrick
Address: 8365 Reed Mine Road
Midland, NC 28107
Telephone: [phone] Fax:
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.)
Donna Wildrick President
Printed Name Title
C1: 1 .(L— ----
Signature Date
S6A4k.�e- l C�yfC��$�—
a Notary Public of the
County of , State of I )aP44-\ (`vttAir1i , hereby
certify that (>r-Nci ( \, Lo c ' personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and al seal is day of Ae6I ,20 Q I .
Notary Signature: 2.�it:"-7(a,
My Commission expires: r,In=ary Public. North Carolina
Coaton County
My Corn ission Expires
Mecklenburg County Land Use and Environmental Services Agency
2145 Suttle Ave.
Charlotte,NC 28208-5237
Phone[phone]