NCC230051_FRO Submitted_20230111

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres, '/z acre or more inside a
watershed, as covered by the Sedimentation Pollution Control Act and the lredell County Land
Development Code, before an acceptable erosion and sedimentation control plan has been submitted
and approved by the lredell County Planning & Development, Erosion Control Section.
(Please type or print)
Part A.
1. Project Name Bethesda Forest
2. Location of land -disturbing activity: County lredell City or Township StateSviIle
Highway/Street Bethesda Rd Latitude 35.711394 Longitude-80.803349
3. Approximate date land -disturbing activity will commence: December 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 12.5
6. Amount of fee enclosed: $ 2,275 _. An application fee of $175.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount (Example: a 8.10-acre application fee is $1575). For projects > than 0.5 acres but no
greater than 0.99 acres in a water supply watershed, a flat fee of $100.00 is assessed.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Michael Foess
Telephone.
E-mail Address michael@themontroseteam. com
Cell# 704-491-3256
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Wellspring Carolina Investments LLC
Name
2133 Garden View Ln
Current Mailing Address
Weddington NC 28104
City State zip
704-936-9624
Telephone
Fax #
2133 Garden View Ln
Current Street Address
Fax Number
Weddington NC 28104
City State Zip
10. Deed Book No. 2901 Page No. 879 Provide a copy of the most current deed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of all
responsible parties on an attached sheet):
Wellspring Carolina Investments, LLC
Name
2133 Garden View Ln
Current Mailing Address
Weddington NC 28104
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
2133 Garden View Ln
Current Street Address
Weddington NC 28104
City State Zip
Fax Number
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2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the designated
North Carolina Agent:
Name
Current Mailing Address
City State
Telephone
Zip
E-mail Address
Current Street Address
City State Zip
Fax Nu
(b) 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 Party is a Corporation, give name and street
address of the Registered Agent:
Mark Boyce
Name of Registered Agent
2133 Garden View Lane
Current Mailing Address
Weddington, NC 28104
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
2133 Garden View Ln
Current Street Address
Weddington, NC 28104
City State Zip
Fax 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 the authority to execute instruments for the Financially Responsible Person). I agree to
provide corrected information should there by any change in the information provided herein.
Type or print name
Signature
"
Title or AuthoYAy
Date
Q 1,4 2 57
11 a Notary Public of the County of
State of North Carolina, hereby certify that ud< �! _ appeared 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 C25 tlay of 20 o?�2
Notary'
My commission expires
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