NCC241441_FRO Submitted_20240510

Print Form
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SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
" RNA ;i' 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this form and an acceptable
erosion and sedimentation control plan has been completed and approved by the Lincoln County Natural Resources Department.
(Please type or print. If the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A
1. Project Name Heartbeats A Pregnancy Care Center Facility
2. Location of land-disturbing activity: Latitude 35.484 Longitude 80.9936
Parcel Identification Number(PIN) 4603665929 Watershed Area
Highway/Street Address N NC 16 Business Hwy; Denver, NC 28037
3. Approximate date land-disturbing activity will commence: March 2024
4. Purpose of development(residential, commercial,industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 1.50
6. Amount of fee enclosed: $ 400.00 .The Standard Permitting application fee of$200.00 per acre
(rounded up to the next acre)is assessed without a ceiling amount(Example: 9 acres total$1,800).The Express
Permitting application fee is a dual charge. The normal fee of$200.00 per acre(rounded up to the next acre)is
assessed without a ceiling amount. In addition,the Express Permitting supplement is$250.00 per acre up to eight
acres,after which the Express Permitting supplemental fee is a fixed$2,000.00 (Example: 9 acres total$3,800.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Local appointed person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kevin Gais E-mail Address [e-mail]
Telephone Cell# [phone] Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Heartbeats A Pregnancy Care Center, Inc. [phone]
Name Telephone Fax Number
5968 S NC 16 Hwy 5968 S NC 16 Hwy
Current Mailing Address Current Street Address
Maiden NC 28650 Maiden NC 28092
City State Zip City State Zip
10. Deed Book No. 3151 Page No. 19 most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s)if applicable:(attach accompanied page to list additional owners):
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip

`r SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
Part B
Person(s)or firm(s)who are financially responsible for the land-disturbing activity(Provide a comprehensive
list of all responsible parties on an attached sheet):
Heartbeats A Pregnancy Care Center. [e-mail]
Name E-mail Address
5968 S. NC16 Hwy
Current Mailing Address Current Street Address
Maiden NC 28650
City State Zip City State Zip
Telephone [phone] N/A
p Fax Number
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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(c) In order to facilitate Permitting, it is necessary to be able to contact the Engineer or other consultant who can
assist in providing any necessary information regarding the plan and its preparation:
Shabeldeen Engineering, PA [e-mail]
Engineering Firm or other consultant E-mail Address
3145 Tate Blvd. SE Hickory NC 28602
Current Mailing Address City State Zip
Dan Shabeldeen 828.320.7252 na
Individual contact person(type or print) Telephone Fax Number

°i� SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
_• 115 West Main Street. Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
(d)Contractors and/or Subcontractors(person(s)or firm(s)engaging in the land-disturbing activity:
Gals Construction
Name of Person or Firm Name of Person or Firm
516 N. Hwy 16
Current Mailing Address Current Street Address
Denver NC 28037
State Zip City State Zip
Kevin Gais
Individual contact person (type or print) Individual contact person (type or pant)
[phone]
Telephone Telephone
Fax Number na Fax Number
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 by any change in the information provided
herein and any other associated documents. I understand that all documents that are associated with this project and
project number are parts of the complete project document.
Permission to Enter on Land
I certify that I am authorized to grant and do in fact grant permission to the Natural Resources Erosion Control Inspector
and his agents to enter on the land in question in connection andior related to this permit.
S . CGr
Ty e or print ame Title or Authority
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I. �_Q(ki tp..a&A. , Q.AC . a Notary Public of the County of L; OW\
State of North Carolina. hereby certify that Q l_initty.1 appeared personally before
me this day and being duly sworn acknowledged that the above form as executed by him.
Witness my hand and notarial seal, this 2-4 day of ScurN , 20 Zs`
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