NCC233354_FRO Submitted_20231116

NTY
HENDE saw"ter c- FINANCIAL RESPONSIBILITY/OWNERSHIP FORM HENDERso __
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before
this form and an acceptable erosion and sedimentation control plan have been completed and
approved by Henderson County Site Development Department. (Please type or print and, if the
question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Sign the original form in BLUE INK.
Part A.
1. Project NameSeasons at Cane Creek Phase 2
2. Location of land-disturbing activity: County Henderson City Fletcher
Highway/StreetHendersonville Road Latitude35.44 Longitude-82.50
Property Identification Number(s) PIN's 9653-73-2354, 9653-72-3947
3. Approximate date land-disturbing activity will commence:June 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):4.75
6. Amount of fee enclosed: $ 1 ,700 . The application fee of$300.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount include a$200.00 plan review fee to
land disturbance fees. (Example: 8.10 ac= $2,900.00).
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 David Jackolyn E-mail Address [e-mail]
Telephone [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Southwood Realty Company,SRC Cane Creek, Inc. [phone]
Name Telephone
P.O. Box 280 165 S. York Street
Current Mailing Address Current Street Address
Gastonia NC 28053 Gastonia NC 28053
City State Zip City State Zip
10. Deed Book No. 3945 Page No. 618 Provide a copy of the most current deed.
Part B. 1688 27
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Southwood Realty Company [e-mail]
Name E-mail Address
P.O. Box 280 165 S. York Street
Current Mailing Address Current Street Address
Gastonia NC 28053 Gastonia NC 28053
City State Zip City State Zip
Telephone[phone] Fax Number

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
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 be any change in the information provided herein.
Herman E. Ratchford, Jr. President
Type or print name Title or Authority
I— s—elf
Signature Date
c--1 1 ro\ , a Nota Public of the County of G�,1--\01
State of "AC , hereby certify that rrs-'�> 1-‘atc Z(• \
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 S day of-l°"•-• "''1► , 20 a 3
d� :r. Notary
i JUNE 17,202J Sea
My commission expires(4,\Y1\( "a3