NCC223502_FRO Submitted_20221014

Gaston County
Gaston Natural Resources Department
1303 Chenyvilie Highway, Dallas, NC 28034 Telephone: [phone]
k Soil Erosion & Sedimentation Control
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 Departments staff.
PART A: (Please type or print and, N question is not applicable, place NIA In blank)
,
1. Project Name Westfall
3.
Location of land -disturbing activity
city of Gastonia Highway/Street
Linwood Road
Approximate date land -disturbing activity will commence. 11 /01/2022
4. Purpose of development (residential, commercial, industrial, etc.) Residential
5.
6.
7.
8.
Q
10.
Total acreage disturbed or uncovered (including off -site borrow and waste areas) 67.00
Amount of fee enclosed $ 20100.00 _67 acres x $300 per acre)
Soil Erosion & Sedimentation Plan Filed? Yes X No
Landowner(s) of Record (Use blank page to fist additional owners)
Mattamy Carolina Corporation
Name
2127 Avrslev Town Blvd- Suite 202
Mailing Address
Charlotte NC 28273
City State Zip
Telephone Number
Name
Mailing Address
City
Telephone Number
State Zip
Indicate Deed Book and Page when; deed(s) or instrument(s) are recorded
Deed Book 5322 Page 0391
Deed Book _ Page
Tax Map No. 306914 Block N/A Lot No. N/A
Page 1

PART B:
1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity
Maffamy Carolina Corporation
Name
2127 Ayrsley Town Blvd., Suite 202
Mailing Address
Charlotte NC 28273
City State Zip
704-507-7547
Telephone Number
Name
Mailing Address
City State Zip
Telephone Number
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street
address of a North Carolina anent.
Name
Mailing Address
City
Street Address
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.
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 if an
individual or his attorney-in4act, 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
herein.
Brian Johnson VP of Land Development
Type or Print Name Title or Authority
04/25/2022
Signature Date
``�
� _ l 4 _ , a Notary Public of the County of t a4kC off- , State of North
Carolina, hereby certify that bi A 00k SYl appeared personally before me this day
and being duly swom acknowledged that the ,� ove form was executed by him.
W' 'my hand and notarial
seal, tthis `` �$: day of 2 0 2Z
UAL Z
om
SE,Ai~ My Cmission Expires
File: Financial Responsibility -Ownership Form.mw
Page 2