NCC242807_FRO Submitted_20240912

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Mecklenburg County Soil Erosion and
Sedimentation Control Ordinance
�Aa s Financial Responsibility/Ownership Form
No person shall initiate any land-disturbing activity covered by Section 6 of the Mecklenburg
County, Mint Hill or Davidson Sedimentation and Erosion Control Ordinances prior to
completing and filing this form with Mecklenburg County Land Use and Environmental
Services. The financially responsible party will be on record as the party to accept any Notices
of Violation or related documents for any non-compliance with the above Ordinances. If the
financially responsible party is out of State, a North Carolina agent must be assigned.
Please Type or Print
PART A
1. Project where land-disturbing activity is to be undertaken: Gateshead Lane
2. Address of land-disturbing activity: 1315 GATESHEAD LN MATTHEWS NC 28105,
1321 GATESHEAD LN MATTHEWS NC 28105, & 1320 GATESHEAD LN
ATTI rwi� � � nnw n�
3. Approximate date land-disturbing activity will commence: 12 1 2023
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 2.08(Ph.I=0.80, PH. 11=0.88,&PH. 111=0.40)
6. Total site acreage: 4.125
7. Landowners of record(use blank pages to list additional owners as necessary):
Owner#1 Name: ZAYNE JOHNSON
Address: 2804 HOUSTON BRANCH RD CHARLOTTE NC 28270
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner#2 Name: CARMEN ALPHA JOHNSON
Address: 2804 HOUSTON BRANCH RD CHARLOTTE NC 28270
Telephone: [phone] Fax:
Email Address: [e-mail]
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 37893 Page 532 Book Page
Book Page Book Page
(continue on back or separate pages as necessary)
Form Revised 12-2016

Continue- Financial Responsibility/Ownership Form
PART B
1. Person(s)or firm(s)financially responsible for this land-disturbing activity:
Person or Firm: ZAYNE JOHNSON
Address: 2804 HOUSTON BRANCH RD CHARLOTTE NC 28270
Telephone: [phone] Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: LC iA� ,��' N-S6�
Address: zOt4 QU5 vkNa-V`d". Qk
10 k- - Ni, )_�6 7 )
Telephone: 70N 77/ V! , q Fax:
Email Address: Z/)t.. 1,e_e)TN 't i (..,-(.6 en,
3. The above informati n is true and correct to the best of my knowledge and belief and was
provided by me while under oath. (This form must be signed by the financially responsible
person if an individual or by an officer, director, partner, attorney-in-fact, or other person
with authority to execute instruments for the financially responsible company or entity, if not
an individual.)
ZAYNE JOHNSON OWNER
Printed N Title
cl//q/ 5 ,
ignaa Date
I, l�----- a( e C__---a e S(fl-e , , a Notary Public of the
County of t -k ee 1t'nC , State of )iOr n Cn G'\r , hereby
certify that 7 at 1 (\e_ Ckrh(l11f---) &r fl personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and arial seal, this ' day of cfl1 rr- 4� 20 23 .
itirliii
Notary Signature: s- �c ``,,BOG BESSO�/,,�
My Commission expires: 5 1 1'S 4QDQ% . 4e. '•��
/ : .Ir o. NRY
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Mecklenburg County Land Use and Environmental Serviczsagt ncy FUs•,3V
2145 Suttle Ave.
Charlotte,NC 28208-5237 �e kV'......... J
Phone[phone] '�.,, 1N i 1 t GO`‘.‘i.iii �
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