NCC222797_FRO Submitted_20220805

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Gaston County
71 Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
�tituxRa �� Soil Erosion & Sedimentation Control
o{ a�
F Financial Responsibility/Ownership
No person may initiate any land -disturbing activity on one (1) or more acres of property in all portions of
Gaston County, except -or that property within the city limits of the incorporated municipalities of Gaston
County who have not adapted the Gaston County Soil Erosion & Sedimentation Control Ordinance,
before this form and an acceptable Soil Erosion & Sedimentation Control Plan have been cornp#pted and
approved by the Gaston County Natural Resources Department's staff.
(Please type or print and, d question is not applicable, place NIA in blank)
PART A:
Project Name _ f—e G Iol, 2Zi
2. Location of land -disturbing activity
City Zr- Highway/Street i' C L r
3- Approximate dale land -disturbing activity will commenceo-'r
4. Purpose of development (residential, commercial, industrial, etc.)r it
5. Iota[ acreage disturbed or uncovered (including off -site borrow and waste areas) _AA �- f
6. Amount of fee enclosed $
7. Soil Erosion & Sedimentation Plan Filed? Yes k,/ No
8. Landowner(s) of Record (Use blank page to list additional owners)
0
10.
Name
a
Mailing Addres,:
City State Zip
Telephone Number
Name
i K
L
Mail g Address
City State Zip
_.—
T tee phone Number
Indicate Deed B Ic and Page where deed(s) or instrument(s) are recorded
Deed Book A, Page 12 f
Deed Book Rage
Tax Map No. Block Lot No.
Page 1

PART B:
1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity
IYdI I IrC7 �} r
Mailin ddress
A/ , / 7
city State i� � zip
o
Telephone Number
Name
A
Mailing Address
City State Zip
Telephone Number
Z If the Financially Responsible Party is not a resident of North Carolina, give name and street
address of a North Carolina agent.
Name
Mailing Address
City
Name
Street Address
State Zip Telephone Number
If the Financially Responsible Party is a Partnership or other person engaging in business under
an assumed nam-, attach a copy of the certificate of assumed name. If the Financially
Responsible Part i; a Corporation give name and street address of the Registered Agent.
Mailing Address Street Address
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.
Type or Print Name j Title or Authority
Signature ' Date
I,a2o�"` V Pf, I jQ1 b - , a Notary Pubii of a County of I P h4 l' , State of North
Carolina, hereby certify tha LLI IL W P.h � �� 0 appeared personally before me this day
a ing duly sworn ackncwledged that e a ove for was ex uted by him.
ltne s my nd d notaral seal, this day of 2.0 3-? .
�ri. . 11
Notary CAROL. K PALS My rni ion Expires
Notary Public - North Carolina e: Financial Responsibility -Ownership Form.mw
Necklanburg County
My commission F.)Orea July 21, 2p23
PR4�0 Page 2