NCC222177_FRO Submitted_20220614

Gaston County
Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
. U� � � Soil Erosion & Sedimentation Control
"et
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 Departments staff.
(Please type or print and, if question is not applicable, place NIA in blank)
PART A:
2.
3.
4.
5.
Project Name Belmont Abby Housing - Wimmer Circle Residence Halls
Location of land -disturbing activity
City Belmont Highway/Street Wimmer circle
Approximate date land -disturbing activity will commence May 01
Purpose of development (residential, commercial, industrial, etc.) Institutional (fut. residence halls)
Total acreage disturbed or uncovered (including off -site borrow and waste areas) 3.59 ac.
6. Amount of fee enclosed $ 1,200.00
7. Soil Erosion & Sedimentation Plan Filed? Yes x No
8. Landowner(s) of Record (Use blank page to list additional owners)
outhem Benedictine Society of North Carolina, Inc
Name
100 BELMONT MT HOLLY RD
Mailing Address
BELMONT NC 28012
City State Zip
704.461.6736
Telephone Number
a
Im
Name
Mailing Address
City State Zip
Telephone Number
Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book 265 Page 55
Deed Book Page
Tax Map No. 217518
Block Lot No.
Page I

PART B:
1 . Person(s) or firm(s) who are financially responsible for this land -disturbing activity
UHS-Belmont 11, LLC (Attn: Jim Harkin)
Name
161 N. 4th Street, Ste. 200
Mailing Address
Columbus OH 43215
City State Zip
513-708-3269
Telephone Number I
Name
Mailing Address
City State Zip
Telephone Number
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street
aaaress Or a Norm uaroima
Barbara R. Christy
Name
230 North Elm Street 230 North Elm Street
Mailing Address Street Address
Greensboro NC 27401 336.749.0490
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.
UHS-Belmont 11, LLC (Attn: Jim Harkin)
Name
161 N. 4th Street, Ste. 200
161 N. 4th Street, Ste. 200
Mailing Address
Columbus OH
Street Address
43215 513-708-3269
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.
Jim Harkin Vice President of Development & Construction
Type, or Pr' e Title or Authority
S'lanaturd Date
L
1, 1 Ar-oj le v _, a Notary, Fublic of the County of FraANA State of 41ei4h -
eamlin hereby certify that I 33M t1I­ayK1'y% _appeared personally before me this day
and being duly sworn acknowledged that the 13bove form was executed by him.
t tness my hand and notarial seal, this �jf` day of Kar; 2 0!17—.
TWjne 21, 2.02-4
ness my h,
SEAL My Commission Expiret
Notary File: Financial Responsibility -Ownership Fonn.mw
RICHARD J BRADLEY
Notary Public
State of Ohio Page 2
My Comm. Expires
6 June 29, 2026