NCC232401_FRO Submitted_20230810

° A' Gaston County
Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
Soil Erosion & Sedimentation Control
Financial Responsibility/Ownership
At, 07-
orit
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 South Point Self Storage
2. Location of land-disturbing activity
City Belmont Highway/Street South Point Road
3. Approximate date land-disturbing activity will commence May 1,2023
4. Purpose of development(residential, commercial, industrial, etc.) Commercial-Self Storage
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 6.28 Ac
6. Amount of fee enclosed $ 2,100.00
7. Soil Erosion & Sedimentation Plan Filed? Yes No
8. Landowner(s)of Record (Use blank page to list additional owners)
Harbor Inn/Brevard LLC
Name Name
301 Airport Road Suite 16
Mailing Address Mailing Address
Greenville South Carolina 29607
City State Zip City State Zip
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deed(s)or instrument(s)are recorded
Deed Book 4992 Page 0268
Deed Book Page
10. Tax Map No. 192178 Block Lot No.
Page 1

PART B:
1. Person(s)or firm(s)who are financially responsible for this land-disturbing activity
WAM South Point LLC
Name Name
4402 Garris Rd
Mailing Address Mailing Address
Charlotte NC 28209
City State Zip City State Zip
704-910-7103
Telephone Number Telephone Number
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street
address of 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). I
agree to provide corrected information should there be any change in the information provided
herein.
Joshua Wilkes Managing Member
Type or Print Name Title or Authority
I, 7Sig atu\\re Date ,�A I_
akt( Cl Ail k:e,(S a Notary Public of the County of rlMQe.,14 1 t(Aif , State of North
Carolina, hereby certify that . _}bSlnA4a LA) l`k•e5 appeared personally before me this day
and being duly sworn acknowledged that the above form was executed by him.
Witness hand an notarial seal, this 2-" day of Mp.(c,( , 20 23 .
01+-2-6 - ?A
-
Not ry SEAL My Commission Expires
• File:Financial Responsibility-Ownership Form.mw
Paul Walters
NOTARY PUBLIC
Mecklenburg County,NC
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