NCC233422_FRO Submitted_20231129

°IINtA Gaston County
11 Gaston Natural Resources Department
ij 1303 Dallas-Cherryville Hwy. Dallas, N.C. 28034 Telephone: [phone]
t4tt Soil Erosion & Sedimentation Control
fel
Financial Responsibility/Ownership
WOO
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: / I-
1. Project Name C,�erry i
2. Location of land-disturbing activity
City , .Vita Highway/Street Q 4)W.- 9,0041
Latitude , '` C': _ _ Longitude-8(.38i8
3. Approximate date land-disturbing activity will commence
4. Purpose of development (residential, commercial, industrial, etc.) tZeSagittliat-5;
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 51.00
6. Amount of fee enclosed$ 't'elfiGUS;. aitX
7. Soil Erosion &Sedimentation Plan Filed? Yes Enclosed C_ No El
8. Landowner(s)of Record(Use blank page to list additional owners)
P.c o t Yu,
Name Name
( i Norl.t. (_/an k Dave. 5c �Pfau
ailing() ress Mailing Address
�.(Atsga-le 4r;2oHc.. R(N1g.
City State Zip City State Zip
0^ kV-- a7q
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deed(s)or instrument(s)are recorded
Deed Book Page `all 7
Deed Book Page
10. Tax Map No. Block Lot No.
092c64q -26(160 7Ro -J140077394 -249DO -).69oa7‘79. .
_ 16100-2983 -2,69007804 ooa7a i/ -,; 690076510 -�69oa27��16
-)6400`%6? 40-ant- 4t -2695075 g -a69oo7I , , -4690o?7gc
—ad100071�3I
Page 1

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. ^n
/• I'luikot� �cMe o� �La . Ike, tc:►�llor &(VW'
Name J Contact Name for Inspection Reports
t3 4.1jotiyi'yi �'Por e PI• CGy+l�r.fSrow /�'Lf��u c�nr�vv�zS,£m
Street an Mailing Address Email Address
Ltia4-1. /1/ 2W7 7oil-k I-Ittig6
City State Zip Telephone Number
7011-CHw-3g0t)
Telephone Number Fax Number
2. If the Financially Responsible Party is not a resident of North Carolina, give the name and street
address of a North Carolina accent.
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.
0 (-Or(k)r ii)v, Se v [,e, 6,;v nr,y
Name 1 //��
2 G/e4.,„v 4tle__ Sulfi►_ S50
Street and Mailing Address Email Address
Qate,'mLI At 97ioi
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.
- I,.✓.. .JL tc.-.h.7 v\ c.c�..,J 1J e.0 e-10 0.1,1,.1^ t 4:6 k.4-1'"'t
Type or Print Name Title or Authority
, r4 11/21a0 7.
11 , `JJ' `
Signature Date '
I, `A.Pc a a Notary Public of the County of Md,;G14.16.1 ,State of North
Carolina, hereby certify that ECx+Y appeared personally before me this day
and being duly sworn acknowledged that the above forth`'was executed by him.
Wit ss 1 ly han a notarial seal,��� �j ��y�of
atet : f '`, P F<6�i,�k Z. . Z.�S
N ty� ', �"A� My Commission Expires
F.
PUBLIC% UBLIC v'
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