NCC242086_FRO Submitted_20240710

CI.
2' Gaston County
Gaston Natural Resources Department
- . Dallas, N. . 2 4 Tele hone: 704-922-4181
f, 1303 Dallas-Cherryville Hwy C 803 p
, � Soil Erosion & Sedimentation Control
t
, 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 Covenant Village Parking Lot
2. Location of land-disturbing activity
City Gastonia Highway/Street 1351 Robinwood Road
3. Approximate date land-disturbing activity will commence 03-01-2024
4. Purpose of development(residential,commercial, industrial, etc.) Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 1.4 AC
6. Amount of fee enclosed$ 800
7. Soil Erosion &Sedimentation Plan Filed? Yes No x
8. Landowner(s)of Record (Use blank page to list additional owners)
Covenant Village Inc
Name Name
1351 Robinwood Road
Mailing Address Mailing Address
Gastonia NC 28054
City State Zip City State Zip
704-867-2319
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book 5054 Page 1665
Deed Book Page
10. Tax Map No. PARCEL#: 301615 Block Lot No.
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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.
Covenant Village Inc. Dale Melton-CEO
Name Contact Name for Inspection Reports
1351 Robinwood Road [e-mail]
Mailing Address Email Address
Gastonia NC 28054 980-259-6260
City State Zip Telephone Number
704-867-2319
Telephone Number Fax 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 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 name and street address of the Registered Agent.
Name
Mailing Address Email 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.
Dale Melton CEO
Type o int Name Title or Authority
12/19/2023
Signature Date
I, r- , a N tary Public of the County of c--��1 , State of North
Carolina, hereby certify that ( �-'�' / -}7)� appeare personally before me this day
and being duly sworn acknowledged that th above form was executed by him.
Witness my hand and notarial seal,this / 1 day of7)e , 2L1
Kristi Marvin 4 3 ' 8
Notary NOTARY PUBLIC SEAL My Commission Expires
Gaston County File:Financial Responsibility-Ownership Form.mw
North Carolina
My Commission Expires April 3,2028
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