NCC240455_FRO Submitted_20240219

CITY OF MONROE STANDARD SPECIFICATIONS AND DETAIL MANUAL
07.06 EROSION CONTROL FORMS AND CHECKLISTS
07.06.01 EROSION CONTROL FINANCIAL RESPONSIBILITY FORM
No person may initiate any land-disturbing activity as defined in Chapter 158 of the Monroe City Code prior to
completion of this form,and an applicable and acceptable erosion and sedimentation control plan has been approved by
the City of Monroe Engineering Department. (Please type or print)
Part I
1. Name of Project Cedar Meadows
2, Address where land disturbing activity will take place 552 N. ML King Blvd.
3. Approximate date disturbing activity will commence 03 / 01 / 2023
4. Purpose of development(residential, commercial, industrial,etc.) Residential
5. Total acreage of land to be disturbed or uncovered 59.8 ac
6. Amount of fee enclosed(fee will be the amount of current policies per acre multiplied by the total number
of acres or any part of an acre from number 5. i.e. 7.28 acres equals 8 acres.) $6,400
7. Agent to contact should sediment control issues arise during land disturbing activity
Name John Brunner Phone [phone]
8. Landowner(s)of Record(use blank page to list additional owners)
AG EHC II (SDH)Multi State 2, LLC
Name Name
160 Mine Lake Ct Ste 200
Mailing Address Mailing Address
Raleigh, NC 27615
160 Mine Lake Ct Ste 200
Street Address _ Street Address
Raleigh, NC 27615
Phone [phone] Phone
Fax Fax
9. Indicate Book and Page where deed of the property where land disturbing activity will take place is recorded
(use blank page to list additional owners)
08830 08830
Book Book
Pa g e 0525-0530 Pa e 0531-0535
g
10. Tax Map Parcel Number where land disturbing activity will take place 093 __ 160 _- 14A
07-18 Permits, Checklists, and Forms
Division 07

CITY OF MONROE STANDARD SPECIFICATIONS AND DETAIL MANUAL
Part II
1. Person(s)or firm(s)who are financially responsible for this land disturbing activity(use blank page to list
additional owners)
Name SDH Charlotte, LLC Name
Mailing Address PO Box 311 Mailing Address
Midland, NC 28107-8502
Street Address 4297 Highway 24/27E Street Address
Suite B, Midland, NC 28107-8502
Phone [phone] Phone
Fax Fax
2. A) If the Financially Responsible Party is not a resident of North Carolina,give name and address of a North
Carolina Agent
Name of Registered Agent
Mailing Address
Street address City State Zip
Phone Email Fax
B) lithe Financially Responsible Party is a Partnership or other person engaging in business tinder an assumed
name,attach a copy of the Certificate of Assumed Name. If the Financially Responsible Party is a
Corporation,give the name and street address of the Registered Agent:
Name of Registered Agent Matthew Chisholm
Mailing Address 4297 Hwy 24/27E, Suite B Midland NC 28107-8502
Street address City State Zip
Phone [phone] [e-mail]
Email Fax
3. The above information is true and correct to the best of my knowledge and belief and was provided by me
under oath. I agree to provide corrected information should there be any change in the information provided
herein.(This form must be signed by the financially responsible person if an individual or his attorney 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)
Type or Pri t Nam Matthew Chisholm Title Affiliate President
D
Signature ti
_ Date ii / 7 / 2�
2 3
I, 'aii,a, �,U,Arnq��r((i� ,a Notary Public of the County of. UM On ,State of North Carolim,
hereby certify that Nitil�Tl�thDl1 al/ appeared personally before me this day and being tidy sworn acknowledged
that the above form was executed by him,
t1)
Witness my hand and notarial seal,this±DIT day of OVQX i tI • (91O9
SEAL7.----.04h.d... 1jiliA., •
Rachel Tomlin (No at ,)
NOTARY PUBLIC Olt A I ✓)
Union County My commission expires OS
North Carolina 07-19 Permits,Checklists,and Forms
My Commission Expires July 28,2027 Division 07