NCC215467_FRO Submitted_20210930

..b... Mecklenburg County Soil Erosion and
Sedimentation Control Ordinance
°�r pia Financial Responsibility/Ownership Form
A�
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 for 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: Dorman Road Townhomes
i,
2. Address of land -disturbing activity:
13160 Dorman Road, Pineville
3
EJ
Approximate date land -disturbing activity will commence: May 03
Month Day
Purpose of development (Residential, Commercial, Industrial, etc.): RESIDENTIAL
5. Approximate acreage of land to be disturbed or uncovered: 1.05
6. Total site acreage: 2.214
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: Wellspring Carolina Investments, LLC
Address: 2133 Garden View Lane, Matthews, NC 28104
Telephone: [phone]
Email Address: [e-mail]
Owner #2 Name:
Address:
Telephone:
Email Address:
Fax:
Fax:
2021
Year
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 29 Page 390 Book Page
Book Page Book Page
(continue on back or separate pages as necessary)
Fomi Revised 12-2016

Continue - Financial Responsibility/Ownership Form
PART S
1
Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Wellspring Carolina Investments, LLC
Address: 2133 Garden View Lane, Matthews, NC 28104
Telephone:
[phone]
Email Address: [e-mail] 4
Fax:
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Wesley S. Hinson
Address: 309 Post Office Drive
Telephone:
Indian Trail, NC 28079
[phone]
Email Address: [e-mail]
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.)
Mark Boyce
Printed Name
Signature
Manager
Title
3-12- Z/.
Date
a Notary Public of the
County of State of 1 VkC,Qltk�O' V'- , hereby
certify that
personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial seal, this 12 day of )"I 20__,,2
Notary Signature:
My Commission expires: I - P
Mecklenburg County Land Use and Environmental. Services Agency
2145 Suttle Ave.
Charlotte, NC 28208-5237
Phone [phone]
`k0TA q'V
MY Comm. EV.
11/6/2022
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