NCC243266_FRO Submitted_20241024

a
Mecklenburg County Soil Erosion and
0 Sedimentation Control Ordinance
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: Pine Lake Country Club
2. Address of land-disturbing activity: 550
4 Lebanon Road, Mini Hit NC 28277
3. Approximate date land-disturbing activity will commence: October 1 2024
Month t)ay Year
4. Purpose of development(Residential, Commercial, Industrial, etc.): Commercial
5. Approximate acreage of land to be disturbed or uncovered: 15.'9 AC.
6. Total site acreage: 162.15 AC.
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner#1 Name: Pine Lake Country Club, Inc
Address: PO Box 690490
Charlotte, NC 28277
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner#2 Name:
Address:
Telephone: Fax.
Email Address:
8. Indicate Book and Page where the deed or instrument is filed(use blank pages to list
additional deeds or instruments as necessary):
Book 1601 page 405 Book Page
Book 8499 page 776 Book Page
(continue on back or separate pages as necessary)
RIMS Rs,aal 12-2t0:6

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s)or firm(s) financially responsible for this land-disturbing activity:
Person or Firm: Pine Lake Country Club, Inc
Address: PO Box 690490
Charlotte, NC 28277
Telephone: [phone] Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Bert Morales
Address: PO Box 690490
Charlotte, NC 28277
Telephone: [phone] Fax:
Email Address: [e-mail]
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.)
Bert Morales General Manager
Prin19.7
Title
6/a s/
Signature Date
I, yOgreIeQ A- , a Notary Public of the
County of in d> , State of IJ 9 R Coed L/A/4 , hereby
certify that 6 CAT B personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and nota ' seal, this Itie6/4" day of /1l i4 j , 20a .
Xui�ruri
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`a Mecklenburg .
County r-
S. MyComm. Exp. Mecklenburg County Land Use and Environmental Services Agency
09 01.1C-2026 �P`�
2145 Suttle Ave.
�i//�HrCAR0' ```�� Charlotte,NC 28208-5237
Phone[phone]