NCC216120_FRO Submitted_20211115

9/21 /21, 3:07 PM
Rowan County
Financial Responsibility/Ownership Form Sedimentation Pollution Control Ordinance
No person may initiate any land -disturbing activity on one or more acres as covered by the ordinance before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Rowan County
Environmental Management Department.
Part .A Parcel ID Number
462005,4620060001,
460152
I. Project Name
Grant's Landing Single Family Subdivision
2. Location of land -disturbing activity (Highway/Street)
Rowan Mill Road
Latitude Longitude
35.657-80.525
3. Approximate date land -disturbing activity will be commenced
01 /01 /2022
J. Purpose of development (residential, commercial, industrial, etc.)
Residential
5. Approximate acreage of land to be disturbed or uncovered
67
6. Person to contact should sediment control issues arise during land -disturbing Cell Phone Number
activity
7045785688
Justin Mueller
Email Address
[e-mail]
https://www. rowancountync.gov/FormCenter/Print?formlD=96&Preview=YES&Save=False&savedProgresslD=546 1 /3

9/21 /21, 3:07 PM
Rowan County
7. Landowner of Record
Forest Glen Inc
Name
Landowner of Record
Kent Grace Steele & Charles Edward Steele
Name
Current Mailing .Address Current Mailing Address
212 Ferncliff Dr 1 South Street
Salisbury, NC 28147 Great Neck, NY 11023
S. Recorded in Deed Book Number Page Number
738 / 700 / 712 458 / 169 / 793
Part B
1. Person or Firm who are financially responsible for this
land -disturbing activity
Shiloh Church Development Group, LLC
Name of Person(s) or Firm(s)
Person or Firm who are financially responsible for this
land -disturbing activity
Name of Person(s) or Firm(s)
Current Mailing Address Current Mailing Address
51 Union Street South, Suite 100
Concord, NC 28025
Phone Number Phone Number
7045785688
a. If the Financially Responsible Party is not a resident of North Carolina, give name and street address of a North Carolina
Agent.
Name of Agent
Current Mailing Address
Name of Agent
Current Mailing Address
Phone Number Phone Number
https://www.rowancountync.gov/FormCenterlPrint?formlD=96&Preview=YES&Save=False&savedProgresslD=546 2/3

9/21/21, 3:07 PM
Rowan County
b. 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 Party is a Corporation, give the name and street
address of the Registered Agent.
Name of Registered Agent
Current Mailing Address
Current Street Address
Telephone Number Telephone Number
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 signet) 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).
agree to provide correctional information should there be any change in the information provided herein.
Name Title or Authority
Signature Date r�MM II
mm/dd/yyyy
..... ... ............................................................................................................................................................................
I. A 1 J ,t S'rrfa I nl r of the County of�� State of North Carolina,
hereby ecrtiij that ■ �fr} , frappeared personali5' beln: c me ibis d,t� a d Irciug tll r swrtrn a itnn%ifralgeri
that the above form was executed by Inn +her. Witness my hand and seal of Notary, this rlal of
Notary
[ 4,,,1, J. R,dqt
Seal
Checklist
Download a copy of the Erosion "n,5edimentation
QQ,Mral Plan Checklist WDF),
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https://www.rowancountync.gov/FormCenter/Print?formID=96&Preview=YES&Save=False&savedProgressID=546 3/3

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