NCC222642_FRO Submitted_20220725

NOUR
Mecklenburg County Soil Erosion and
E ' Sedimentation Control Ordinance
° GA 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.
PART A
1
Please Type or Print
Project where land -disturbing activity is to be undertaken: 5500 Wilgrove Mint Hill
2. Address of land -disturbing activity:
5500 Wilgrove Mint Hill Road, Mint Hill, NC 28227
3. Approximate date land -disturbing activity will commence: May
1
Month Day
4. Purpose of development (Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered.
6. Total site acreage: 3.100 acres
2.086 acres
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: Christopher S. Bennett
Address: 7834 Cornflower Commons Drive Mint Hill, NC 28227
Telephone:
[phone]
Email Address: [e-mail]
Owner #2 Name:
Address:
Telephone:
Email Address:
Fax:
Fax:
2022
Year
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 36763 page 544-548 Book
Book Page
ITIM
Page
Page
Form Revised 12-2016
(continue on back or separate pages as necessary)

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Po cnn nr Firm • Christopher S. Bennett
Address: 7834 Cornflower Commons Drive Mint Hill, NC 28227
Telephone: [phone]
Email Address: [e-mail]
Fax:
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.)
Christopher S. Bennett
pn a ame Title
Signature Date
I, La t f ± fA I C�1h.ar c l.� � , J r , a Notary Public of the
County of _� a'T'a0 h , State of ! D ►'} - L CWrQ i ,h4 , hereby
certify that -4c)1, k t° Y 8 - C'n Y 't�E -- personally appeared
before me this day and under oath acknowledged that this form was IIexecuted by him/her.
Witness my hand and notarial sea[ day of !-I ((� r l 1 , 20
C i 1 I _
Notary Signature:
My Commission expires:
Mecklenburg County Land Use and Environmental Services Agency
2145 Suttle Ave.
Charlotte, NC 28208-5237
Phone [phone]