NCC222722_FRO Submitted_20220815

NaURQ
r - Mecklenburg County Soil Erosion and
o . Sedimentation Control Ordinance
r oy. CA 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: Alton Creek
2. Address of land -disturbing activity: 6412 Matthews -Mint Hill Road Charlotte NC 28227
3
11
Approximate date land -disturbing activity will commence: December 1
Month Day
Purpose of development (Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered. 22.42 A.C.
6. Total site acreage: 31.49
7.
Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: Phil Chambers
Address: 4530 Park Road Suite 410 Charlotte NC 28209
Telephone: [phone]
Email Address: [e-mail]
Owner #2 Name:
Address:
Telephone:
Email Address:
Fax:
Fax:
2021
Year
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 13888 page 136
mllq
Page
Book Page
Book Page
Form Revised 12-2016
(continue on back or separate pages as necessary)

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Tri Pointe Homes
Address: 6325 Ardrey Kell Rd Suite 125 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: N/A
Address: N/A
Telephone: N/A
Email Address: N/A
Fax: N/A
I 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.)
Printed Name, AI Title
Signature
County of 0
certify that
before me this day and ur
Witness my hand and n
Notary Signature: '
My Commission expires:
t` i I let (I&I-1
Date
""' I , a Notary Public of the
IStateb,Of ` �/l%� , hereby
� _. �L T-A /` ( V\ personally appeared
oath acknowledged that this fo was executed by him/her.
seal, this I day of S� 20.
Mecklenburg County Land Use and Environmental Services Agencv
2145 Suttle Ave. AMBER M EGAN
Charlotte, NC 28208-5237 NOTARY PUBLIC
Phone [phone] UNION COUNTY
North Carolina
My Commission Expires MAY 2, 2,024