NCC216200_FRO Submitted_20211110

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Gaston County
gGaston Natural Resources Department
a 1303 Cherryville Highway, Dallas, NC 28034 Teiephone: 704-922-4181
94 �
AUR4 Soil Erosion & Sedimentation Control
i� ram
Financial Responsibility/Ownership
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
approved by the Gaston County Natural Resources Department's staff.
(Please type or print and, if question is not applicable, place NIA in blank)
PART A:
1. Project Name Jehk lns ralrq .iraVel t at
2. Location of land -disturbing activity
City Gastonia Highway/Street
3. Approximate date land -disturbing activity will commence
Jenkins Pwry Woad
4. Purpose of development (residential, commercial, industrial, etc.)
12-01-2021
Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 5,35 ac,
6. Amount of fee enclosed $ P, 900, 00
7. Soil Erosion & Sedimentation Plan Filed? Yes ✓ No
8. Landowner(s) of Record (Use blank page to list additional owners)
01
IL
6 0 dIA � 8Y1 i
Name
_9W
Mailin Address
Doy; Sv A C 4056
City State Zip
Telephone Number
N
m) ry Gu
Name
Mailing Address
City State Zip
Teiephone Number
Indicate Deed Bq�k a d Page where deed(s) or,jpstrument(s) are recorded
Deed Book �, (l ip Page 11A b
Deed Book Page
Tax Map No. & /37587 Block Lot No.
Page I

PART B.
1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity
Cro531101nt Property Graup - Jed Ins Parry, II C
Name
563 Jettan 5t. • Suite 200
Mailing Address
Payidson NC 28036
City State Zip
C709 61, 25;
Name
Mailing Address
City State Zip
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street
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 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). I
agree to provide corrected information should there be any change in the information provided
herein.
TV-f tie r,
Type or Print Na Title or Authority
Signat Date
1,7 a>ary Public of the County of Wr.ti State of North
Carolina, hereby certify that appeared personally before me this day
and being duly sworn acknowledged that the abo e form was executed by him.
N trnr
Witness my hand and nottaariial_ see day of d r > , 242 f
Notary Zti Q'[A Rt AL'. My Commission Expires
File: Financial Responsibility -Ownership Form.mw
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Page 2
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