NCC231183_FRO Submitted_20230505

__ Gaston County
Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
4, Soil Erosion & Sedimentation Control
Financial Responsibility/Ownership 7
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 Department's staff.
(Please type or print and, if question is not applicable, place N/A in blank)
PART A:
1. Project Name S New Hope Road Townhomes
2. Location of land-disturbing activity
City Gastonia, NC Highway/Street 2675 Lowell Bethesda Road
3. Approximate date land-disturbing activity will commence February 1, 2022
4. Purpose of development (residential, commercial, industrial, etc.) Residential (Townhomes)
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 16.91 acres
6. Amount of fee enclosed $ 5,100
7. Soil Erosion &Sedimentation Plan Filed? Yes X No
8. Landowner(s)of Record (Use blank page to list additional owners)
Harris Land Holdings LLC
Name Name
2857 Westport Road
Mailing Address Mailing Address
Charlotte NC 28208
City State Zip City State Zip
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deed(s)or instrument(s) are recorded
Deed Book 5214 Page 2306
Deed Book 5214 Page 2339
5214 2450
10. Tax Map No. 148797, 148825, 148902, 300798 Block Lot No.
3" ' 0 7 2021 IP Page 1
h,.

PART B:
'1. Person(s)or firm(s)who are financially responsible for this land-disturbing activity
MTSCLT, LLC
Name Name
2857 Westport Road
Mailing Address Mailing Address
Charlotte NC 28208
City State Zip City State Zip
[phone]
Telephone Number Telephone Number •
2. 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 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
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. / .
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f eui t� °`y-ti, ,- C
Type or Print Nam _ Title or Authority
X.
Signature Date
+
I, ci a .. .7au� fir' k, , a Notary Public of the County of I(vttc]cke cq , State of North
Carolina, hereby certify that Ns.,kck; n1 appeared personally`before me this day
and being duly sworn acknowledged that t above form was executed by him.
Witness my hand and notarial seal,this 5 day of Oc.n�,r , 208-1 .
t_.:..4200.2cie- 447,,Z9
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Not SEAL My Commission Expires
File:Financial Responsibility-Ownership Form.mw
MARK DAVID KRAWCZYK Page 2
NOTARY PUBLIC
LINCOLN COUNTY,NC
My Commission Expires 7.7.2028
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