NCC223403_FRO Submitted_20220930

°°°N�'A Gaston County
Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
Soil Erosion & Sedimentation Control
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4 Financial Responsibility/Ownership
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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
2
Project Name Community Public Charter School
Location of land -disturbing activity
City Stanley Highway/Street N. Main St.
3. Approximate date land -disturbing activity will commence August, 2022
4. Purpose of development (residential, commercial, industrial, etc.) Institution
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 17.98 ac
6. Amount of fee enclosed $ 6,000.00
7. Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s) of Record (Use blank page to list additional owners)
7
1181
WRE-Earth Farms, LLC
Name
46 Lizotte Dr., Ste 1000
Mailing Address
Marlboro, MA 01752
City State Zip
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 4846 Page 1040
Deed Book Page
Tax Map No. 3579573603
Block
Lot No.
Page 1

PART B:
1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity
Hubrich Contracting, Inc
Name
4321 Medical Park Dr., Ste 100
Mailing Address
Durham, NC 27704
City State Zip
919-471-2895
Telephone Number
Name
Mailing Address
City State Zip
Telephone Number
If the Financially Responsible Parry is not a resident of North Carolina, give name and street
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NA
Name
NA
Mailing Address Street Address
NA
City State Zip Telephone Number
3. 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 Part is a Corporation give name and street address of the Registered Agent.
NA
Name
NA
Mailing Address Street Address
NA
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 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). I
agree to provide corrected information should there be any change in the information provided
here'n.
Y_'
TypeprPyipA Name Title or Authority
/ Signature j Date
a Notajy Public of the County of I Zc i C�.✓i �, State of North
Carolina, hereby certify that /4? 41'P /4-/GL r /, appeared personally before me this day
and being duly sworn acknowledged th% Jae�aJ�gve form as executed by him.
Witnes my hand and notarial seal,��t �� W,,pfy�gf ( 2
Notary _ E My Commission Expires
File: Financial Responsibility -Ownership Form.mw
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Page 2
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