NCC217033_FRO Submitted_20220120

°O°N� Gaston County
Gaston Natural Resources Department
a 1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
k �
Soil Erosion & Sedimentation Control
N OAi
Financial Responsibility/Ownership
dl'p�RTffi��
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 Deoartment's staff.
(Please type or print and, if question is not applicable, place N/A in blank)
PART A:
1. Project Name Mountain View Grove
2. Location of land -disturbing activity
City Gastonia Highway/Street Mitchem Road
3. Approximate date land -disturbing activity will commence Jan 2021
4. Purpose of development (residential, commercial, industrial, etc.) Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 4.00 ac
6_ Amount of fee enclosed $ 1,200.00
7. Soil Erosion & Sedimentation Plan Filed? Yes YFC N
8. Landowner(s) of Record (Use blank page to list additional owners)
True Homes, LLC
Name
2649 Breckonridge Center Dr. Suite 104.
Mailing Address
Monroe NC 28110
City State Zip
Telephone Number
Name
Mailing Address
City State Zip
Telephone Number
9. Indicate Deed Book and Page where deed(s) or instruments) are recorded
Deed Book 5234 Page 1 12 6
Deed Book Page
10. Tax Map No. 201465, 205196, 196386, Block
136535
Lot No.
Page I
Scanned with CamScanner

PART B:
t Person(s) or firm(s) who are financially responsible for this land -disturbing activity
Name
2649 Breckonrldgp Centre Or
Mailing Address
Mon roe —NC 28110
City __ State Zip
Telephone Number
Name
Mailing Address
City State zip
Telephone Number
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street
auuicna wi a rvUf to Uarohna agent.
Name
Mailing Address Street Address
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.
Name 3 '
Mailing Address Street Address
/11-Nf L' NC_ a� 1/0 7U�-f-���-
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.
Shaun Gasparini Program Manager
Type or Print Name
Sign
Title or Authority
ai�o�Nr+ y f T 3-
I Date
I, ` a Nota ubliq of the County of State of North
Carolina, he by certify that '( appeared personally before me this day
and being duly sworn acknowledged that the ve for w ex cuted by m.
wtnes my hand axial seal, this_? ay of 2 .
run
Notary RFAI My Commission xpires
KUNJAL PATEL File Financial Responsibility -Ownership Form.mw
NOTARY PUBLIC
Union County
North Carolina
My Commission Expires January 28, 2025
Page
Scanned with CamScanner