NCC242951_FRO Submitted_20240925

City of Charlotte & Mecklenburg County
Soil Erosion and Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land-disturbing activity covered by Chapter 17, Article 2 of the Charlotte City Code or
Section 6 of the Mecklenburg County Sedimentation and Erosion Control Ordinance prior to completing and filing this
form with the City of Charlotte Engineering and Property Management Department, Land Development Services Division
or Mecklenburg County Land Development Services. The financial responsibility party will be on record as the party to
accept any Notices of Violation or related documents for any non-compliance of the City of Charlotte Soil Erosion and
Sedimentation Ordinance. 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: Mallard Creek Galloway
2. Address of land—disturbing activity: 10908 Mallard Creek Road Charlotte, NC 28262
3. Approximate date land-disturbing activity will commence: Fall 2024
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 2.19 ac
6. List total site acreage: 15.52 ac
7. Landowners of Record (Use blank page to list additional owners):
Name: DRB Group North Carolina, LLC
Address: 227 West Trade Street, Suite 400
Charlotte, NC 28202
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
Signature: 7GI/Z.--=-40,--
Name:
Address:
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
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Continue - Financial Responsibility/Ownership Form
Name:
Address:
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 38985 Page 311
38985 Page 316
Page
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City of Charlotte & Mecklenburg County
Soil Erosion and Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land-disturbing activity:
Person or Firm: DRB Group North Carolina, LLC
Address: 227 West Trade Street, Ste 400
Charlotte, NC 28202
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
3. The above information 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.)
Jay Colvin Division President
Printed Name Title
Signature, Date
I, Tn.a G,rc sbea, , a Notary Public of the County
of Union , State of kbrth Ccum nou , hereby
certify that (3264 CeiUI Yl personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notarial seal, this Ii day of :40::� ��' 20 ��
Notary Signature: �j/VLCt
o, ifs
My Commission expires: t'7-24)2.g
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CHARLOTTE.•y`"W DUNT`�,,�,a•`'�.
ENGINEERING&PROPERTY
MANAGEMENT Page t
Land Development Division
600 East Fourth Street,Charlotte,North Carolina 28202-2844
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