NCC230201_FRO Submitted_20230124

CITY OF GREENSBORO
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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No person may initiate any land -disturbing activity covered by the Sedimentation Pollution Control Act before this form
has been completed and filed with the Sediment and Erosion Control Section of the City of Greensboro. (Please type
or print and, if questions are not applicable, place N/A in the blank).
Part A:
1. Project Name: Mercy Hill Church
2. Location of land -disturbing activity 1317 Pleasant Ridge Road Greensboro NC 27409
3. Approximate date land disturbing activity will be commenced August 2022
4. Development type: Commercial ✓ Industrial Institutional_ MF residential SF residential
5. Approximate acreage of land to be disturbed: 15.95
6. Has an erosion and sediment control plan been filed? Yes , No
7. Landowner(s) of Record (attach pages to list additional owners):
Mercv Hill Church 336-698-4070
Name Telephone
2335.114 Presidential Drive 2335-114 Presidential Drive
Current Mailing Address
Durham NC 27703
City State
Zip
kbroderi ck @mercyhil Ich urc
Email
Current Physical Street Address
Durham NC 27703
City State Zip
8. Deed County: Guilford Book: 8561 Page: 2631
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Keith Broderick Telephone: [phone]
E-mail kbroderick(cDmercvhillchurch.com Other:
Part B:
1. Company(ies) or firms) 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.
Mercy Hill Church 336-698-4070 kbroderickOmercyhillchurc
Name Telephone Email
2335-114 Presidential Drive 2335-114 Presidential Drive
Current Mailing Address Current Physical Street Address
Durham NC 27703 Durham NC 27703
City State
Zip
City State
Zip

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:
NIA
NIA NIA
Name
Telephone Email
NIA
NIA
Current Mailing Address
Current Physical Street Address
NIA NIA NIA
NIA NIA NIA
City State Zip
City State Zip
(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:
NIA
NIA NIA
Name
Telephone Email
NIA
NIA
Current Mailing Address
Current Physical Street Address
NIA NIA
NIA NIA NIA
City State Zip
City State Zip
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.
Robert Herrinaton
Type or print name
]S
Signature
Lead Pastor of Ministries and Operations
Title or Authority
Date
k I, RAV AM QiG�AYASCh a Notary Public of the County of G t/11 1 �'D rof
State of ���� t 1 C GAY D jam_ hereby certify that 1ag-
Personally accepted before me this day and under oath acknowledged that the above form was
executed by owner(s).
Witness my hand and notarial seal, this IIIday of rJ �A�t , 20 2 2
My Commission expires Al
9,0d'
SARAH RICHARDSON
Notary Public, North Carolina
Guilford County
My Commission E-pireg
November 04, 2024

City of Greensboro, NC
Grading Permit Application
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Owner Information:
Company Mercy Hill Church
Address P.O. Box 39209
Greensboro, NC 27438
Project Information:
Project Name Mercy Hill Church
Address 1317 Pleasant Ridge Road Greensboro NC 27409
Area Graded 15•45 Acres and/or sq.ft.
Proposed Use of Property Religious Facility
Permit #:
Contact Keith Broderick
Phone No, 336.402-0308
Email [e-mail]
Latitude 36.12075 Longitude -79.96487
Tax Map 7816540716
Site Area 23.12 Acres and/or sq.ft.
Zoning CU-PI
Brief Description of Project Location The project is located on Pleasant Ridge Rd. approximately 600 feet east from the intersection of Brigham
Rd. and Pleasant Ridge Rd.
Brief Description of Development Plan This project is a proposed religious facility approximately 80,382 sf. building and associated
parking lot and driveways.
If this application is approved by the properly designated authorities and a grading permit issued, the undersigned does hereby agree to
comply with all applicable City regulations under the Greensboro Soil Erosion and Sedimentation Control Ordinance as described in
Chapter 30-12-6 of the Greensboro Land Development Ordinance.
Before beginning any grading operation, call for an on -site pre -construction meeting, and when area has been protected, call for final
inspection.
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Signature of owner, developer, or agent: /Date:1( �Z i 12 2
Approved by
Permit No.
Tracking No.
Surety Amount
Surety Number
Temporary Measures Approved
Final Inspection Approved
Date Approved
FOR OFFICE USE
Date
Date
Tracking Type: TRC
Surety Type: LOC
Surety Expiration Date
Date
Date
Grading
SCB HOD Check

CITY OF GREENSBORO
WATER RESOURCES DEPARTMENT
GREENSBORo SEDIMENT AND EROSION CONTROL SECTION
RESPONSIBILITY: The owner of any property within the City limits of the City of
Greensboro where a land -disturbing activity is taking place, shall be solely responsible for any
off -site damage to adjacent property or to City streets (mud and erosion in street), that may
have been caused by the lack of erosion control measures and poor maintenance. The soil
erosion measures detailed on your plans are the minimum required by the City of Greensboro.
When conditions become apparent the owner/developer may be required by the City of
Greensboro to have his/her engineers to design or redesign additional measures/devices to
assure land protection.
1. Erosion Control measures shall be installed prior to grading and according to plans or as
directed by the City of Greensboro's Erosion Control Inspector.
2. The approval of the Erosion Control plan does not mean that additional measures may
not be required to stop off -site sediment.
3. The Owner/Developer shall require the Contractor to take every reasonable precaution
throughout construction to prevent erosion of soil and sedimentation of streams, lakes,
reservoirs, other impoundments, ground surfaces or other property, as required by
Chapter 30, Soil Erosion and Sedimentation Control, of the Code of Ordinances, City of
Greensboro, North Carolina.
4. The Owner/Developer is responsible for maintaining the erosion and sediment control
devices for the duration of the construction.
a. Inspect the site after each rain and periodically to ensure workmanship is according
to plan and site is in compliance with the Erosion Control Ordinance.
b. Repair or replace damaged or inoperative devices as directed by the Soil Erosion
Inspector within a reasonable time or time set forth by the inspector.
c. Keep mud off city streets
5. If eroded soil from the site is deposited on adjacent property, public street or into a
waterway, the Owner/Developer shall be responsible for returning the adjacent property,
city street or waterway to its original condition satisfactorily to the City or the owner of
the property.
6. After placement of asphalt binder on newly constructed street the shoulder shall be
seeded within fourteen (14) days according to the Seeding Specifications.

7. Temporary or permanent groundcover shall be provided on all perimeter areas and
slopes 3:1 or greater within 7 calendar days following completion of any phase of
grading. Provide groundcover for all disturbed areas within 14 calendar days following
completion of construction or development.
8. The Owner/Developer must plan site work so stone placement on drive entrance,
driveway and parking lot can start immediately after fine grading.
9. The Owner or Responsible Party is responsible for the long-term maintenance of the
groundcover on the property. Groundcover must be maintained to a degree that
prevents soil erosion and sedimentation at all times. The City of Greensboro has the
authority to require changes in the owner's groundcover maintenance plan in order to
stop soil erosion and sedimentation at any time.
Section 30-5-5.4 (B) — Specific Civil Penalties
Any person who violates any of the provisions of this chapter, or rules or orders adopted or
issued pursuant to this chapter, or who initiates of continues a land -disturbing activity for which
an erosion control plan is required except in accordance with the terms, conditions, and
provisions of an approved plan, shall be subject to a civil penalty of up to five thousand dollars
($5000.00) per day. No penalty shall be assessed until the person alleged to be in violation has
been notified of the violation by registered or certified mail return receipt requested, or other
means. The notice shall describe the violation with reasonable particularity, give the person a
reasonable time period to correct the violation and state that failure to correct the violation will
result in assessment of a civil penalty of up to five thousand ($5000.00) per day or other
enforcement action including criminal penalties. Each day of continuing violation shall constitute
a separate violation. The city council shall determine the amount of the civil penalty to be
assessed under this subsection and shall make written demand for payment upon the person in
violation, and shall set forth in detail a description of the violation for which the penalty has been
imposed. In determining the amount of the penalty the governing body shall consider the
degree and extent of harm caused by the violation and the cost of rectifying the damage. If
payment is not received or equitable settlement reached within thirty (30) days after demand for
payment is made the matter shall be referred to the city attorney for institution of a civil action in
the name of the city in the appropriate division of the general courts of justice for recovery of the
penalty. Any sums recovered shall be used to carry out the purposes and requirements of this
chapter. /
Signature:-,,,►% Date: A 61 Z -2 Z Z
Owner (Print): Robert Herrington
Date: June 27, 2022
Project Address: 1317 Pleasant Ridge Road Greensboro NC 27409

City of Greensboro Sediment and Erosion Control
Plan and Grading Permit Submittal Checklist
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Project Title: Mercy Hill Chuch
Disturbed Area: 15.95 AC.
Plan Tracking Number:
All plans are required to meet the minimum design criteria set forth in the
North Carolina Erosion and Sediment Control Planning and Design Manual.
Required submittal for initial review:
X Completed grading permit application and financial responsibility/ownership form (in PDF format)
X Plan (In PDF format)
X Calculations for all sediment and erosion control measures (in PDF format)
Location information:
X Location map including roads, streets, drainage ways and relevant landmarks. A north arrow and scale
should be included.
X Latitude and Longitude at the project entrance in decimal degrees.
General site features:
X City of Greensboro cover sheet (Completed)
X Acreage of disturbance
X Total site acreage
__2L Soil types
__2L North Arrow and scale (Maximum of 1" = 60')
__X_ Legend (Provide symbols for all measures and reference them to the construction details)
X Property lines and ownership information for the site and adjoining properties
X Land use of surrounding areas
X Limits of disturbance
X Existing contours (topography)
X Proposed contours (topography)
X Hydrogeological features (rock outcrops, springs, seeps, wetlands, streams, lakes, ponds, dams etc.)
X Designation and buffer zones for hydrological features
X Existing and proposed road locations (include elevations and contours)
X Existing and proposed building or structure locations (include elevations and contours)

X Lot numbers, building numbers and/or addresses
X Planned and existing utilities and easements (Include any pipe sizes, materials, etc.)
X Soil stockpile areas (Must be within the site's sediment and erosion control measures)
X Borrow and/or waste areas (Note: If the same person conducts the land -disturbing activity & any related
borrow or waste activity, the 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 Waste Management. If the land -disturbing activity and any related borrow or
waste activity are not conducted by the same person, they shall be considered separate land -disturbing
activities and must be permitted either through the Sedimentation Pollution Control Act as a one -use
borrow site or through the Mining Act.)
Site drainage features:
X Drainage delineation maps for existing and planned drainage patterns. Include off -site areas that drain
through the project as well as areas below the project that will be directly affected by drainage from the
site.
X Drainage delineation maps to all proposed sediment and erosion control measures
X Location and details for existing and proposed storm sewer systems and culverts
X Location and contours for existing and planned channels
Sediment and erosion control measures and site stabilization:
X Location and detail of construction entrance (City of Greensboro standard #217 or 436)
X Location and detail of silt fence (See section 6.62 in the N.C. Erosion and Sediment Control Planning and
Design Manual for acceptable usage and maximum slope length for silt fence applications.) (City of
Greensboro standard #430)
Location, detail and calculations for sediment traps (See section 6.6 in the N.C. Erosion and Sediment
Control Planning and Design Manual for options and acceptable usage.)
X Location and method of protection for storm inlets (See section 6.5 in the N.C. Erosion and Sediment
Control Planning and Design Manual for options and acceptable usage.) (City of Greensboro Standard #
430)
X Location, detail and method of stabilization for channels. Include calculations, specifications for proposed
liners and staple patterns. (See section 6.3 in the NC Erosion and Sediment Control Planning and Design
Manual for options and acceptable usage.)
X Location, detail and method of stabilization for temporary and permanent diversions. (See section 6.2 in
the N.C. Erosion and Sediment Control Planning and Design Manual for options and acceptable usage.)
N/A Location and detail for slope drains (See section 6.32 in the NC Erosion and Sediment Control Planning
and Design Manual for options and acceptable usage.)
N/A Design detail for partially installed storm sewers (City of Greensboro Standard #443)

_NZA Method of stabilization for slopes that are greater than 2:1. (Methods of stabilization for slopes steeper
than 2:1 must be shown in detail, and vegetative cover alone is not acceptable. Retaining walls greater
than 5 feet in height require review and permits through Building Inspections)
X Location, details and calculations for all other proposed sediment and erosion control measures
X Specific details and sequencing for any work proposed to be done in streams (See section 6.7 in the N.C.
Erosion and Sediment Control Planning and Design Manual. Copies of all required permits from Federal
and State agencies are required)
Stabilization:
X Provision for ground cover on exposed slopes that are 3:1 or steeper, perimeter slopes, fill slopes, slopes
greater than 50 feet in length, swales, dikes, ditches and high quality water zones within 7 days, and all
other areas within 14 days
X Temporary seeding specifications including method of soil preparation, seed and soil supplement types
and amounts, mulch types and amounts, and method of anchoring (matting or tacking materials)
X Permanent seeding specifications including method of soil preparation, seed and soil supplement
types and amounts, mulch types and amounts, and method of anchoring (matting or tacking
materials)
Other information:
X Construction Sequence related to sediment and erosion control (This is site specific. Should include a pre -
construction meeting, installation of measures and inspection of measures prior to initiation of land
disturbance, specifics related to grading and development of the site including relevant utility installation,
stabilization of drive and parking areas, stabilization of other areas as applicable, removal of temporary
measures, and a final inspection to close the grading permit.)
X Provisions for monitoring and self -inspection requirements of the NPDES NCG0100000 permit. It should
be noted that self -inspection requirements are required until the site is stable and the grading permit is
closed.
Required submittal prior to permitting:
X Grading permit application and financial responsibility/ownership forms (original signed and notarized)
X Plan (Sealed, signed, and including all pages and information contained in electronic submittals)
X Surety (Sites with 5 acres or more disturbed require a surety of $2000.00 per disturbed acre)
N/A Copies of all permits from Federal and State agencies (Army Corps 404 permit and Water Quality 401
certification where required)