NCC232943_FRO Submitted_20231019

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place N/A in the blank.)
Part A. Family Dollar
1. Project Name y
2. Location of land-disturbing activity: County Cleveland City or Township Shelby
Highway/Street Stage Coach Trl Latitude 35.416253 Longitude-81 .645526
3. Approximate date land-disturbing activity will commence: Dec 1 , 2021
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 .1 1
6. Amount of fee enclosed: $ 130 . The application fee of 665.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is$585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed Yes
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Will Stronach E-mail Address [e-mail]
Telephone [phone] Cell# 919-270-1750 Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Name ++ Telephone Fax Number
2iok`I, SkytNe. Cow-�- `ta•:1 'I
Current Mailing Address Current Street Address
St„.121k"i N� -Zv s"D
City State Zip City State Zip
10. Deed Book No. IS-2-7 Page No. k 441 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
S9 Fps. LL-C._ W iAgse `row Proil/A-4s•co
Name E-mail A ress
400E Jft �s • '+ lOf
Current Mailing Address Current Street Address
SZate'SkdI N L 7-7 401
Gity State Zip City State Zip
Telephone qlq 270 r S 0 Fax Number q (q 4Sr -.'t

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) 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
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
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
the 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.
�:%,\A‘q w. f'l . S0i.a. M0.i.nc.5.o
Type or print name Title or Authority
Signature Date
I, Sh9 Woo , -ee , a Notary Public of the County of aKC
State of North Carolina, hereby certify that W(t\ OY'(1 . �Y no* appeared
personally before me this day and being duly sworn a knowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of OR MINN , 20 21
T )ttc%-%
No ary
Seal _ � '�+ �81L�G My commission expires U C fD JW ZO
'•FCOUN ; `�.

a 710° County, NC
�� FILED L 0:5,'12 At1
on .. :in31C25L0E2V7
IE E. REECE
DE DS
�j by. RGISTER PAGE 1998
.0Q. -/o ' BOO
RECORDING FEE REV _.
NORTH�A�ROLINA GENERAL WARRANTY DEED
Excise Tax: NONE
Parcel Identifier No. /srjged by County on the_day of ,20_
By:- A
Mail/Box to:
This instrument was prepared b:Robert W.Wolf, ey at Law,Forest City,N.C.
*NO TITLE EXAMINA REQUESTED OR PERFORMED*
Brief description for the Index:
•
THIS DEED made this 13th day of July,2007,by and between/1
GRANTOR lQ GRANTEE
V.A.POWELL and wife, �� GARY POWELL and wife,
RUTH W.POWELL MARILYN POWELL
�4), P.O.Box 463
y olkville,NC 28136
The designation Grantor and Grantee as used herein shall include said parties,lheitbirs,successors,and assigns,and shall include
singular,plural,masculine,feminine or neuter as required by context.
WITNESSETH,that the Grantor,for a valuable consideration paid by the Grantee,titcDeceipt of which is hereby acknowledged,
has and by these presents does grant,bargain,sell and convey unto the Grantee,in fee simple,that certain lot or parcel of land
situated in Number Eight Township,Cleveland County,North Carolina,and more particul r ,described as follows:
O See attached Exhibit"A"for legal description of property. `` �
The property hereinabove described was acquired by Grantor by instrument recorded in Book I5 N k,�c 81 1
A map showing the above-described property is recorded in Plat Book ,Page
NC Bar Association Form No.3©1976,Revised©1977,2002
Printed by Agreement with the NC Bar Association—1981-Chicago Title Insurance Company

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BOOK 1527 PAGE 1199
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VSJ EXHIBIT"A" 10
r Legal Description of Property
LOT NO.1: ��
Being located on the South s dtil
i f Polkville-New House Road about 500 feet from
Polkville,Number 8 Township, land County,and being more particularly described
as follows:
BEGINNING at an iron stake near thoenter of the Polkville-New House Road, same
being the Northeast corner of James Marvin Mode home tract and runs gradually to the
North edge of said road North 73-10 East 0 8 feet to an iron stake in the North edge of
said road,same being Polkville School pro. ' corner;thence with school property line
South 15-43 East 273 feet to an iron stake s Itppl property corner; thence with another
line of school property South 74-15 West 200 f�'t to an iron stake in school property line,
same being the Southeast corner of.9 acre tract deedd James Lee Hunt and wife;thence
with Hunt's East line North 14-45 West 114.7 feYt:*an iron stake, same being James
Marvin Mode's Southeast corner; thence with Mod ' ast line North 16-45 West 146
feet to the BEGINNING,containing 1.1 acre,more oT5,according to a survey of J.D.
Turner,Registered Surveyor,made May 15, 1964.
Same being a part of the 6.2 acre tract as deeded by the Pm ial Insurance Company of
America to John L. Hunt and wife,Kate H. Hunt,by deed d August 31, 1951, and
being of record in the Cleveland County Registry in Deed Bo k 6-L,Page 501,reference
being made to said deed,and the record thereof,for further ident i ation and description
of the said property. O
Being the same land deeded to James Lee Hunt and wife,Betty G.l-Iyitt.by John L.Hunt
and wife,Kate H. Hunt,by deed dated May 22, 1964,and recorded in Book 10-M,Page
208 in the Cleveland County Registry. \22�
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BOOK 1527 PAGE 1500
LOT NO.2: 0,
Being located on the Wit side of Polkville-New House Road about 500 feet from
Polkville, Number 8 Township, Cleveland County, and more particularly described as
follows:
BEGINNING at an iron stake Lro er of Polkville School property and runs with the line
of the school property North 15 : West 225 feet to an iron stake in the South edge of
pavement of Polkville-New Hous=•it ence with the edge of said road North 57-00 East
100 feet to a point in the South e. .f said road Northwest corner of James Marvin
Mode's home tract;thence with Mora West line,South 16-45 East 152 feet to an iron
stake,same being Mode's Southwest cor;thence with Mode's South line,North 71-15
East 105 feet to an iron stake,same being Mode's Southeast corner in James Lee Hunt's
line; thence with Hunt's West line, Sout04-45 East 114.7 feet to an iron stake in
Polkville School property line, same being is Southwest corner; thence with said
school property line South 74-15 West 200 f R the place of BEGINNING,containing
.9 acre, more or less, according to a survey of . Turner, Registered Surveyor, made
May 16, 1964.
Same being a part of the 6.2 acre tract as deeded by t& rudential Insurance Company of
America to John L. Hunt and wife,Kate H. Hunt,b d dated August 31, 1951, and
being of record in the Cleveland County Registry in De ook 6-L,Page 501,reference
being made to said deed,and the record thereof,for furth_ tlentification and description
of the said property. `��
Being the same land deeded to James Lee Hunt and wife,Bettie.Hunt by John L.Hunt
and wife,Kate H.Hunt,by deed dated May 22, 1964,and recor�edd in Book 10-M,Page
208 in the Cleveland County Registry. O
For further description and identification, reference is hereby made( feed recorded in
Book 11-U at Page 239 of the Cleveland County Registry,North Carolina.
(DESC.07-Powell,Gary/afr) ��
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TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances thereto belonging to the
Grantee in fee simple. `O
BOOK 1527 PAGE 1501
And the Grantor covenants with the GranCv at Grantor is seized of the premises in fee simple,has the right to convey the same
in fee simple,that title is marketable and Tree and clear of all encumbrances,and that Grantor will warrant and defend the title
against the lawful claims of all persons whomsoever,other than the following exceptions:
IN WITNESS WHEREOF,the Grantor holy executed the foregoing as of the day and year first above written,or if a
corporate,has caused this instrument to be signed' corporate name by its duly authorized officers and its seal to be hereunto
affixed by authority of its Board of Directors,the day allyear first above written.
fi -U 0 (SEAL.)
Powell
f yl / � �p�/
"- 7 R- • Dv 0-1 (SEAL)
Ruth . owell
State of North Carolina-County of Rutherford
I,the undersigned Notary Public of the County and State aforesaid,certify tf .A.Powell and wife,Ruth W.Powell
personally appeared before me this day and acknowledged the due execution of the foregoing instrument for the purposes therein
expressed. Witness my hand and notarial stamp or seal this 40 day of ( JuJJ ( ,2007.
My Commission Expires: (t-Ot (i..?? 4
Notary Pub'
., Atx Cr 1 r )�.
ra''Y r r f ��
tie...^n fs; __..l.l-lea-0.r.
NC Bar Association Form No.3©1976,Revised©1977,2002
Printed by Agreement with the NC Bar Association-1981-Chicago Title Insurance Company