NCC221650_FRO Submitted_20220427

°uvGaston County
Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
,. Soil Erosion & Sedimentation Control
3 7 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 N/A in blank)
PART A:
1. Project Name Penler - Mt. Holly
3.
4.
5.
6.
Location of land -disturbing activity
City Mt. Holly Highway/Street Caldwell Drive
Approximate date land -disturbing activity will commence 05/2022
Purpose of development (residential, commercial, industrial, etc.) Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas) 24.50 AC
Amount of fee enclosed $ 7500.00
7. Soil Erosion & Sedimentation Plan Filed? Yes No
8. Landowner(s) of Record (Use blank page to list additional owners)
�eJ
im
Mt. Holly Owner, L.L.0
Name
2964 Peachtree Rd Nw, Suite 275
Mailing Address
Atlanta GA 30305
City State Zip
415-378-7331
Telephone Number
Name
Mailing Address
City State Zip
Telephone Number
Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book 4909 Page O&W
Deed Book Page
Tax Map No. 3595765217 Block
Page 1

PART[B:
1. Penson(m)orfirn(a)who are financially responsible for this land -disturbing activity
Mt. Holly Owner, L.L.0
Name
2964 Peachtree NW, Suite 275
Mailing Address
Atlanta GA 30305
Cltv State Zip
415-378-7331
Telephone Number
Name
Mailing Address
City State Zip
Telephone Number
2. If the Financially Responsible Party is not a resident of North Candina, give name and street
address of a North Carolina aqent.
Name
Mailing Address Street Address
city State Zip Telephone Number
3. If the Financially Responsible Party isePartnership other person engaging in business under
an assumed name, attach o copy of the certificate of assumed name. If the Financially
Responsible Part iaeCorporation give name and street address ofthe 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 ifen
individual or his aMomoy-in-fact, or, if not an individuo|, by an officer, dioactor, padner, or
registered agent with authority to execute instruments for the financially responsible person). |
agree to provide corrected information should there be any change in the information provided
herein.
Type o ri a Title or Authority
S It
ignat Date
C» / m`�"��"
1p File: rmanpu/ Responsibility-Ownership,onn.mw