NCC233215_FRO Submitted_20231026

°°.,4'2' Gaston County
Gaston Natural Resources Department
' 1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
5E -44 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.
(Please type or print and, if question is not applicable, place N/A in blank)
PART A:
1. Project Name Nixon Road Subdivision
2. Location of land-disturbing activity
City City of Belmont Highway/Street Nixon Road (S.R. 2534)
3. Approximate date land-disturbing activity will commence Summer 2023
4. Purpose of development (residential, commercial, industrial, etc.) Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 12.50 AC.
6. Amount of fee enclosed $3.900.00
7. Soil Erosion & Sedimentation Plan Filed? Yes V No
8. Landowner(s) of Record (Use blank page to list additional owners)
John T & Martha H Hayes Living Trust Thomas Gordon Haves
Name Name
222 Lakeview Dr. 308 Nixon Road
Mailing Address Mailing Address
Belmont NC 28012 Belmont NC 28012
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 2859 Page 0423
Deed Book N/A Page N/A
10. Tax Map No. N/A Block N/A Lot No. N/A
Page 1

PART B:
1. Person(s) or firm(s) who are financially responsible for this land-disturbing activity
Davidson Homes N/A
Name Name
190 N Harrison Av, Suite 200 N/A
Mailing Address 3 Mailing Address
Cary NC 2751. N/A N/A N/A
City State Zip City State Zip
919-868-2147 N/A
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.
N/A
Name
N/A
Mailing Address Street Address
N/A N/A N/A N/A
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.
Mark Altman - Davidson Homes
Name
1903 N. Harrison Av, Suite. 56 '
Mailing Address Street Address
Cary NC 2751,r3 919-868-2147
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.
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Type or Print Name Title or Authority
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Sig ture � Date
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I, //[ Notary Public of the County of GilQke , State of North
Caro Ina ereb that a A/f-rna,1 appeared personallybefore me this day
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and being duly sworn acknowledged that the above form wa§executed by him.
Wits my hand and notarial sell,this /(dti'day of©Ctobev , 20 2-3 .
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Nota 1 AL My Commission Expires
NANCY J. PUBLICMARIH W 0 File:Financial Responsibility-Ownership Form.mw
NOTARYO
Wake CountyPUBLIC
North Carolia o
l My Commission Expires June 6th,2028 8 Page 2