NCC230335_FRO Submitted (2)_20230207

�( 00- Gaston County
Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
��a�A Stormwater
4 Financial Responsibility/Ownership
°��a�e
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 Stormwater Ordinance, before this form and an
acceptable Stormwater Plan have been completed and approved by the Gaston County Natural
Resources Department's staff.
HART A: (Please type or print and, if question is not applicable, place NIA in blank)
Project Name Carolina Riverside - Early EC - Village D2
2. Location of land -disturbing activity
City of Belmont Highway/Street Armstrong Ford Road
3- Approximate date land -disturbing activity will commence 1/1/2023
4. Purpose of development (residential, commercial, industrial, etc.)
Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 21.54
6. Amount of fee enclosed $ 7,700.00
7. Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s) of Record (Else blank page to list additional owners)
N,
Belmon-t #1 US321/74 B s LL
Name
Selwyn Avenue Suite 500
Mailing Address
N -17 1
City State Zip
Telephone Number
Pulte Home Company, LLC
Name
11121 Carmel Commons BlvdSuite
Mailing Address
.Qharlotte NC 28226-4498
City State Zip
704 543-4922
Telephone Number
Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book PB Q97 Page ___PG 068
Deed Book 5354 Page 0111
10. Tax Map No. 307993 Belmont #1 Block NIA _ Lot No. N/A
307989 (Pulte)
450
Page I

PART B:
1. Person(s) or firm(s) who are financially responsible for this property.
_Pulte Home Comoanv. LLC _
Name
11121 Carmel Commons Blvd. Suite 450
Mailing Address
Charlotte. NC 28226
City State Zip
704 543-4922
Telephone Number
Contact Name for Inspection Reports
Email Address
Telephone Number
Fax Number
If the Financially Responsible Party is not a resident of North Carolina, give name and street
address of a North Carolina agent.
NIA
Name
Mailing Address Street Address
City State Zip Telephone Number
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
Mailfng 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 aitorney-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.
Jeremy Huntsman
Type or Print Name
Signatur
Director of Land Development
Title or Authority
11/2/2022
Date
I, t} F. MAte- , a Notary Public of the County of 1 �- State of Nerffi
Carolina, hereby certify that riot r appeared personally before me this day
and bei duly sworn acknowledged that the above form was executed by him.
Witness rhy hand ►i )notarial seal, this 2*4 day of O�s Pl , 2 67-2---
Nol6ry Commission Expires
THOMAS PATANIA, JR. File. Financial Responsibility -Ownership Form.mw
NOTARY PU13UC
Lancaster County, South Carulina
My Commission �F
ire$ January 9, 2027 Page 2