NCC240636_FRO Submitted_20240305

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Mecklenburg County Soil Erosion and
toma
Sedimentation Control Ordinance
4 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: Brandywine Subdivision: Lot 2
2. Address of land-disturbing activity: 1711 Brandywine Dr
3. Approximate date land-disturbing activity will commence: February 20 2024
Month Day Year
4. Purpose of development(Residential, Commercial,Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 0.35 Ac.
6. Total site acreage: 0.4793 Ac
7. Landowners of record(use blank pages to list additional owners as necessary):
Owner#1 Name: Zachary Houle
Address: 3821 Sky Haven Dr
Charlotte, NC 28209
Telephone: [phone] Fax: n/a
Email Address: [e-mail]
Owner#2 Name: Leah Essink
Address: 3821 Sky Haven Dr
Charlotte, NC 28209
Telephone: [phone] Fax: n/a
Email Address: [e-mail]
8. Indicate Book and Page where the deed or instrument is filed(use blank pages to list
additional deeds or instruments as necessary):
Book 38451 page 304 Book Page
Book Page Book Page
(continue on back or separate pages as necessary)
Form Revised 12-2016

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s)or firm(s)financially responsible for this land-disturbing activity:
Person or Firm: Zachary Houle
Address: 3821 Sky Haven Dr
Charlotte, NC 28209
Telephone: [phone] Fax: n/a
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone: Fax:
Email Address:
3. 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.)
Zachary Houle Land Owner
Printed Name Title
1/25/2 LI
S a e Date
I, IllV►v. 1N• Pots , a Notary Public of the
County of ML'C.y--. ,0 IOEA.v - , State of N OVilA ro Lt 11& , hereby
certify that —Zack a-Ka- H L personally appeared
before me this day and under oath acknowledged that this form``^^was executed by him/her.
Witness my hand and notarial seal,this o�5 "day of (kL 4L u ,20 Alt .
Notary Signature: LA.).
My Commission expires: 0 2•1 bl I ?O
P0P ��f°
'°A. Mecklenburg County Land Use and Environmental Services Agency
OTAR 2145 Suttle Ave.
MY v- Charlotte,NC 28208-5237
COPAhAiSSlQ ExP@€DES Phone[phone]
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