NCC224046_FRO Submitted_20221207

Gaston County
fc Jr Gaston Natural Resources Department
0 1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
Soil Erosion & Sedimentation Control
\a all
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.
(Please type or print and, if question is not applicable, place N/A in blank)
PART A:
1. Project Name Landers Chapel Rd/Lots 1-3
2
3.
4.
5.
6.
Location of land -disturbing activity
City Cherryville Highway/Street Landers Chapel Rd
Approximate date land -disturbing activity will commence 12-01-22
Purpose of development (residential, commercial, industrial, etc.) residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas) 2.0
Amount of fee enclosed $ 600.00
7. Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s) of Record (Use blank page to list additional owners)
10.
Helmsman Homes, LLC
Name
116 Gasoline Alley, Suite 105
Mailing Address
Mooresville NC 28117
City State Zip
980-500-1251
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 5350 Page
Deed Book 1178 Page
Tax Map No. 307182,307180,307181
Block
Lot No. Lots 1-3
Page 1

PART B:
1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity
Todd Farlow
Name
116 Gasoline Alley, Suite 105
Mailing Address
Mooresville NC 28117
City State Zip
980-500-1251
Telephone Number
Name
Mailing Address
City State Zip
Telephone Number
If the Financially Responsible Party is not a resident of North Carolina, give name and street
address Ot a North Carolina agent.
Name
Mailing Address Street Address
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.
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 -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).
agree to provide corrected information should there be any change in the information provided
herein.
Todd Farlw
Type 6r Print
Signature
Legal Counsel
Title or Authority
10-31-22
Date
I, ,(' ck_1 l j j a , a Notary Public of the County of L''l CO I't , State of North
Caro l- n' a, hereby c`e�l'fy that a Cl d u vj appeared personally before me this day
and being duly sworn acknowledged that the above form was executed by him.
Witness m 3 ) day of hand and notarial seal, this (j r ��, j 2 U i Z, ,,,,,�����a""'^"'►►►,,,,���,,
SEAL My Com ission xpires = j�' —�O C•'
File: Financial Respons ty=Ov&ership F r rn.
2