NCC215271_FRO Submitted_20210927

~� Mecklenburg County Soil Erosion and
5 1 Sedimentation Control Ordinance
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: College Street
2, Address of land -disturbing activity: College Street Lots 52-55
3, Approximate date land -disturbing activity will commence: 11 01 2021
Month Day
4, Purpose of development (Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 1.16
6. Total site acreage: 0.769
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: PCM Holdings, LLC -David Blackley
Address. PO Box 67, Matthews, NC 28106
Telephone: [phone]
Fax:
Email Address: David BlacAkleyPbellsouth.net
Owner #2 Name:
Address:
Telephone:
Email Address:
Fax:
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 27880 page 560
Book Page
Book Page
Book Page
Year
Form Revised 12-2016
(continue on back or separate pages as necessary)

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Tcv s, Lxy,- S LL c T _
Address:
0
Telephone: 0` (� �3g 22� Fax:
Email Address:
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone:
Email Address:
Fax:
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.)
Printed Name
Signature
1,
County of.
certify that
Pry ie� Cana �Cr'
Title 41
Zo 2. i
Date
, a Notary Public of the
State of b} CN= A) At , hereby
personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand a tarial seal, this day of � MTV ��B�ek
Notary Signature. � 0���'',••...•°'4��iS7
My Commission expires: 015-za
Mecklenburg County Land Use and Environmental Services Agency
2145 Suttle Ave.
Charlotte, NC 28208-5237
Phone [phone]
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