NCC222181_FRO Submitted_20220613

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place N/A in the blank.)
Part A. Palisades at HickoryCreek
1. Project Name
2. Location of land -disturbing activity: County Cleveland City or Township Shelby
Highway/Street S Dekalb Street Latitude 35.26668 Longitude 81.54291
3. Approximate date land -disturbing activity will commence: November 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 23.66
6. Amount of fee enclosed: $ 1560 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name William E. Ratchford E-mail Address [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Southwood Realty Company
[phone]
Name
Telephone Fax Number
165 S York Street
165 S York Street
Current Mailing Address
Current Street Address
Gastonia NC 28052
Gastonia NC 28052
City State Zip
City State Zip
10. Deed Book No. 1823 Page No.
1347 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially
responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties
on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Southwood Realty Company
[e-mail]
Name
E-mail Address
165 S York Street
165 S York Street
Current Mailing Address
Current Street Address
Gastonia NC 28052
Gastonia NC 28052
City State Zip
City State Zip
[phone]
Telephone
Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(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 name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
Fax 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 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
the 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.
Herman E Ratchford Jr
Type or print name
.x�
Signature
State of North Carolina, hereby certify that -
personally before me this day and being
executed by him.
President - Southwood Realty Company
Title or Authority
C`v4' \
Date
a Notary Public of the County of C—>a,S�:j
c� o, �F is ��Z-Q _TC appeared
luly sworn acknowledged that the above form was
_�\
Witness my\+hand and notarial seal, this l6 day of,-�� �� , 20 a \
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Ju�7a4A N tary I
` My commission expires
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