NCC241628_FRO Submitted_20240530

°_ °II.144'a Gaston County
Gaston Natural Resources Department
�i►111�G 1303 Dallas-Cherryville Hwy. Dallas, N.C. 28034 Telephone: [phone]
4a� Soil Erosion & Sedimentation Control
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 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 G4 ( 12r &. l20
2. Location of land-piisturbing activity I
City Highway/Street 4JYILE , vC-kiG
Latitude 35. 135153 Longitude — 8l. 04c 6.d1%
3. Approximate date land-disturbing activity will commence 4- II '
4. Purpose of development (residential, commercial, industrial, etc.) teC4i i.(
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 411
o3-
6. Amount of fee enclosed $ Z000
7. Soil Erosion & Sedimentation Plan Filed? Yes_ ✓I Enclosed No I
8. Landowner(s)of Record (Use blank page to list additional owners)
61u PaAL Sow 64G.1_ 1.14
Name Name
04-f, r\tkvWca 1201.
Mailing Address Mailing Address
(� Wt(i . SG 241 fo
City State Zip City State Zip
(2O4) d?.S - 134-
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deed(s)or instrument(s) are recorded
Deed Book 5--4 S S Page 'q
Deed Book Page
10. Tax Map No. 3 I 3 t'i Block Lot No.
Page I

r
PART B:
1. Person(s)or firm(s)who are financially responsible for this land-disturbing activity. NOTE:if FRP is not the
Landowner of Record Part A: 8.. include with this form the landowner's signed and notarized written consent for the
applicant to submit a draft erosion and sedimentation control plan and to conduct the anticipated land disturbing
activity.
D o vq illv "t`e.`�dtk Court tN Jvtc �a
Name Contact Name fo Inspection Reports
5i-q, Ni av i c--o ()rive campy- ® •►1a0 E4 s . Cow,
Street and Mailing Address Email Address
G. 2A It o
City State Zip Telephone Number
oq) 9177 ' 1”-4-
Telephone Number Fax Number I
I
2. If the Financially Responsible Party is not a resident of North Carolina, give the name and street
address of a North Carolina agent.
Name
Street and Mailing Address Email 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 Party is a corporation, give the name and street address of the Registered Agent.
Name
Street and Mailing Address Email Address
City State Zip Telephore 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.
Lau re. (C . MOSpacIde f.---
Typ or Print Name Title or Authority
�' l� 1P e P—
i
Date
gnature {{
* I, enn t cP Y O hC Q , a Notary Public of the County of M eCU Cn61/4 State of North
Carolina, hereby certify that (1�1)Ye4 tN M C cpCd d'h appeared personally b e me this day
and g duly s orn acknowledged :hat'he form was executed by him
W nes my han nd renal seal, this _day of J 1w V i. , 2 0(D —I
i\)We.rhbPr aoel a� a ~7
Not SEAL My Commission Expires
4....,.... Jennifer Shao
NOTARY PUBLIC
` Mecklenburg County,NC Page 2
My Commission Expires November 20,2027

Erosion and Sedimentation Control Permit Submittal Checklist
Document Submittal Requirements
FRO has created a Citizens Self Service (CSS)
Completed, Signed, and Notarized FRO ✓Portal Account and the account has been
FForm (to be signed by person financially verified
responsible for the project and no item
should be left blank, mark N/A if needed) [ 7 Copy of most current Deed for the site
❑ Landowner of Record Authorization Letter l ! Name and contact information of NC Registered
(if the FRO is not the landowner of record) Agent, if applicable
Copy of Certificate of Assumed Name, if ✓ Complete set of Erosion Control Plans and
applicable Calculations (utilize remaining checklists to
ensure complete submittal)
Plans -Location Information and General Site Features
✓" Project Location t,-- Roads, Streets
✓ North Arrow t/" Scale
1 7' Adjoining lakes, streams, or other major
drainage ways Property lines
�, —
✓ Legend ✓ Existing Contours
✓ Proposed Contours 1/ Limit and acreage of disturbed area
ffPlanned and existing building(s) location — Planned and existing road(s) location and
and elevations t/ elevations
Lot and/or building numbers t/ Land use of surrounding areas
1.1
" Rock outcrops ,/ Seeps or springs
`'� Wetland limits Easements
Streams, lakes, ponds, drainageways,
ti dams; also, any official wetland, stream, Boundaries of the total tract
and/or watercourse delineation report(s)
Plans - Borrow and Waste Areas
If the same person conducts the land-disturbing activity and any related borrow or waste activity shall
constitute part of the land-disturbing activity unless the borrow or waste activity is regulated under the
Mining Act of 1971, or is a landfill regulated by the Division of Solid Waste Management. If the land-
disturbing activity and any related borrow or the same person does not conduct waste activities, they
be considered separate land-disturbing activities.
�✓ Stockpiled topsoil or subsoil location(s) [Street profiles
Plans-Vegetative Stabilization
Planned vegetation with details of plants, seed,
mulch, fertilizer NOTE: Plan should include
reas and acreage to be stabilized i/ provisions for groundcover in accordance with
NPDES Construction Stormwater General
Permit NCG010000
Page 3

ii
L✓' Specifications of permanent and temporary ✓ Method of soil preparation
vegetation
Plans- Site Drainage Features
E✓Existing and planned drainage patterns
(include offsite areas that drain through t - Size of areas to be disturbed (acreage)
project)
Size and location of culverts and sewers L....----Soils information (type, special characteristics)
'-'''/Design calculations and construction for Design calculations, cross-sections, and method
culverts and storm sewers L - of stabilization of existing and planned channels
— — (include temporary linings)
Design calculations and construction details
LIAt,//of energy dissipaters below culverts and
storm sewer outlets (for rip-rap aprons, I 9' oil information below culvert and storm sewer
IL�_ outlets
include stone sizes(diameters) and apron
dimensions)
Design calculations and construction details Name of receiving watercourse or name of
to control groundwater i.e., seeps, high ✓municipal operator (only where stormwater
water table. etc. discharges are to occur)
Plans- Erosion Control Measures
t'' Legend ��Location of temporary and permanent measures
Construction drawings and details for Tr Design calculations and construction details for
temporary and permanent measures sediment basins and other measures
El Maintenance requirements during Person responsible for maintenance during
construction construction
Maintenance requirements and responsible
Efr-v-
person(s)for permanent measures
Plans- Other Requirements
Tv/Narrative describing construction sequence , Narrative describing the nature and purpose of
(as needed) the construction activity
Construction sequence related to sedimentation
and erosion control (include installation of
Bid specifications regarding erosion control measures prior to initiation of the land
disturbing activity and removal of measures
after areas they serve have been permanently
stabilized)
Page -i