NCC223798_FRO Submitted_20221115

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A o Gaston County
Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
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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 Department's staff.
PART A: (Please type or print and, if question is not applicable, place N/A in blank)
1. Project Name WINTERLAKE PHASE 2
2. Location of land -disturbing activity
City GASTONIA Highway/Street Windley Drive
3.
4.
5.
6.
Approximate date land -disturbing activity will commence 08/25/22
Purpose of development (residential, commercial, industrial, etc.) RESIDENTIAL
Total acreage disturbed or uncovered (including off -site borrow and waste areas) 2.97 Ac.
Amount of fee enclosed $ 900.00
7. Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s) of Record (Use blank page to list additional owners)
9
10.
Elizabeth Ann Williams
Name
2218 Union Road
Mailing Address
Gastonia NC 28054
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 5257 Page 0648
Deed Book Page
Tax Map No. Block Lot No.
Page 1

PART B:
1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity
J.P Development Group, LLC.
Name
4301 Fairview Oaks Drive
Mailing Address
Charlotte NC 28211
City State Zip
704-617-7200
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
duuress Ui a ivortn uaroiina a
NA
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.
Thomas D. Pearson
Name
4301 Fairview Oaks Drive
Mailing Address Street Address
Charlotte NC 28211 704-617-7200
City State Zip Telephone 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 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.
Thomas D. Pearson
Type or Print Name
S,nature
Manager
Title or Authority
Date
I, T!S'4/1 -� L->iAQt0 's� , a Notary Public of the County of Atfex&e�-o I,,ct , State of North
Carolina, hereby certify that :ZAe— r iappeared personally before me this day
and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this Y_ day of , 2 L,L .
/Z-Zp-Z,170
Notary SEAL My Commission Expires
File: Financial Responsibility -Ownership Form.mw
JOSEPH E. WHALEY, JR.
N DTARY PUBLIC Page 2
Iredell, County, North Carolina