NCC221685_FRO Submitted_20220502

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Mecklenburg County Soil Erosion and
£o M�};�_: 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:
Lot #13 - Davidson Farms Subdivision
2. Address of land -disturbing activity:
19559 Kistler Farm Road, Davidson, NC 28036
3. Approximate date land -disturbing activity will commence: April 29 2022
Month Day
4. Purpose of development (Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 0.78
6. Total site acreage:
0.97
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: Matthew & Calire COnway
Address: 6419 Myston Lane
Huntersville NC 28078
Telephone: [phone]
Fax:
Email Address: [e-mail]
Owner 42 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 36790 page 858 Book Page
Book Page Book Page
(continue on back or separate pages as necessary)
Year
Form Revised 8-2014

Continue - Financial Responsibility/Ownership ]Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Monterey Bay- Charlotte, LLC
Address: 18637 Northline Drive, Suite F
Cornelius, NC 28031
Telephone: [phone] Fax:
Email Address: [e-mail]
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.)
Rick Constable
Printed Na
Signature
I, KuI '
County of
certify thal
President
Title
4-7-22
Date
a Notary Public of the
114 hereby
personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and nota/ial seal, this _� day of 1'1 I , 20 Z 2
Notary Signature:
My Commission expires: b-5 -
7.'�S
Mecklenburg County Land Use and Environmental Services
700 N. Tryon Street
Charlotte, NC 28202-2236
[phone]
FAX [phone]
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