NCC241833_FRO Submitted_20240625

Gaston County
e '� ` .mot Gaston Natural Resources Department
4�u,r 1303 Dallas-Cherryville Hwy. Dallas, N.C. 28034 Telephone: [phone]
l..�da�� Soil Erosion & Sedimentation Control
0
a 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 Prime Senior Living
2. Location of land-disturbing activity
City Gastonia Highway/Street Redbud Dr
Latitude 35.2430 Longitude -81.1210
3. Approximate date land-disturbing activity will commence March 1,2024
4. Purpose of development(residential, commercial, industrial, etc.) residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 8.64 ac
6. Amount of fee enclosed$36M13°
7. Soil Erosion &Sedimentation Plan Filed? Yes Enclosed No n
8. Landowner(s)of Record (Use blank page to list additional owners)
New Hope Baptist Church
Name Name
2024 Redbud Dr
Mailing Address Mailing Address
Gastonia NC 28056
City State Zip City State Zip
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deed(s)or instruments)are recorded
Deed Book 800 Page 270.271,272,273
Deed Book Page
10. Tax Map No. 148683 Block Lot No.
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.
Prime Gastonia Senior Living,LLC. Joel Locker
Name Contact Name for Inspection Reports
11622 El Camino Real,Suite 1038 [e-mail]
Street and Mailing Address Email Address
San Diego Ca 92130 917-365-4872
City State Zip Telephone Number
917-365-4872
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 agent.
Paracorp Incorporated
Name
176 Mine Lake Ct#100
Street and Mailing Address Email Address
Raleigh NC 27615
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.
Name
Street and 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.
Joel Locker Member
Type or Print Name Title or Authority
/ /30/202y
Signature Date
('el/ll-c,e )lea
I, Se;r'\ Go 1,A2,le Z 06-I ru , a Notary Public of the County of Sc --1 k, )r''>u ,State of Neftii—
earaiine, hereby certify that 1 u-e ( 1 (,c 1- -0), appeared personally before me this day
and being duly sworn acknowledged that the above form was executed by him.
Witne and notarial seal,this 30 day of )(-\:n ,2 0-19 .
Pv Jv . `). 202 (o
Nota SEAL My Commission Expires
SARA GONZALEZ CASTRO
Notary Public-California s
3 3 San Diego County I
4 It
Commission p 2425144 Page 2
2026
My Comm.Expires Expresres Noy 4,

Erosion and Sedimentation Control Permit Submittal Checklist
Document Submittal Requirements
FRO has created a Citizens Self Service (CSS)
Completed, Signed, and Notarized FRO Ell Portal Account and the account has been
riForm(to be signed by person financially verified
responsible for the project and no item
should be left blank, mark N/A if needed) a Copy of most current Deed for the site
Landowner of Record Authorization Letter l l Name and contact information of NC Registered
(if the FRO is not the landowner of record) Agent, if applicable
1 Copy of Certificate of Assumed Name, if Complete set of Erosion Control Plans and
applicable ri
Calculations(utilize remaining checklists to
ensure complete submittal)
Plans-Location Information and General Site Features
✓ Project Location l Y Roads, Streets
V North Arrow I- Scale
Adjoining lakes, streams, or other major
✓ drainage ways ✓ Property lines
✓ Legend ✓ Existing Contours
V Proposed Contours ✓ Limit and acreage of disturbed area
`n Planned and existing building(s)location ri Planned and existing road(s) location and
and elevations elevations
✓ Lot and/or building numbers V Land use of surrounding areas
V Rock outcrops V Seeps or springs
✓ Wetland limits V Easements
Streams, lakes, ponds, drainageways,
Cdams; also, any official wetland, stream, V Boundaries of the total tract
and/or watercourse delineation report(s)
Plans-Borrow and Waste Areas
If the same person conducts the land-disturbing activity and any related borrow or waste activity shall
constitute part of the land-disturbing activity unless the borrow or waste activity is regulated under the
C
Mining Act of 1971, or is a landfill regulated by the Division of Solid Waste Management. If the land-
disturbing activity and any related borrow or the same person does not conduct waste activities, they
be considered separate land-disturbing activities.
I l Stockpiled topsoil or subsoil location(s) n Street profiles
Plans-Vegetative Stabilization
Planned vegetation with details of plants, seed,
mulch, fertilizer NOTE: Plan should include
piAreas and acreage to be stabilized n provisions for groundcover in accordance with
NPDES Construction Stormwater General
Permit NCG010000
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(� Specifications of permanent and temporary
I vegetation ✓ Method of soil preparation
Plans-Site Drainage Features
✓� Existing and planned drainage patterns n
(include offsite areas that drain through I I Size of areas to be disturbed (acreage)
project)
EllSize and location of culverts and sewers a Soils information (type, special characteristics)
1 1 Design calculations and construction for ri Design calculations, cross-sections, and method
I I culverts and storm sewers l I of stabilization of existing and planned channels
(include temporary linings)
Design calculations and construction details
111 of energy dissipaters below culverts and Soil information below culvert and storm sewer
storm sewer outlets (for rip-rap aprons, El outlets
include stone sizes(diameters)and apron
dimensions)
Design calculations and construction details Name of receiving watercourse or name of
ato control groundwater i.e., seeps, high n municipal operator(only where stormwater
water table, etc. discharges are to occur)
Plans- Erosion Control Measures
JJLegend E] Location of temporary and permanent measures
I I Construction drawings and details for 111 Design calculations and construction details for
temporary and permanent measures sediment basins and other measures
riMaintenance requirements during 1 i Person responsible for maintenance during
construction construction
ElMaintenance requirements and responsible
person(s)for permanent measures
Plans-Other Requirements
I I Narrative describing construction sequence 111 Narrative describing the nature and purpose of
(as needed) the construction activity
Construction sequence related to sedimentation
and erosion control (include installation of
I I Bid specifications regarding erosion control I7 I critical measures prior to initiation of the land-
disturbing activity and removal of measures
after areas they serve have been permanently
stabilized)
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