NCC242083_FRO Submitted_20240710

1 Ay141.
Gaston County
.,t Gaston Natural Resources Department
L °� j. 1303 Dallas-Cherryville Hwy. Dallas, N.C. 28034 Telephone: [phone]
IttR Soil Erosion & Sedimentation Control
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 Covenant Village Stonecrest Villa Apartments
2. Location of land-disturbing activity
City Gastonia Highway/Street 1351 Robinwood Road
Latitude 35.247161 Longitude -81.150031
3. Approximate date land-disturbing activity will commence 7-1-2024
4. Purpose of development(residential, commercial, industrial, etc.) Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 2.05
6. Amount of fee enclosed$$1,200
7. Soil Erosion &Sedimentation Plan Filed? Yes Enclosed X No
8. Landowner(s)of Record(Use blank page to list additional owners)
Covenant Village, Inc.
Name Name
1351 Robinwood Road
Mailing Address Mailing Address
Gastonia NC 28054
City State Zip City State Zip
704-867-2319
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deed(s)or instrument(s)are recorded
Deed Book 1278 Page 0747
Deed Book Page
10. Tax Map No. Parcel# 115862 Block Lot No.
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11. If the Financially Responsible Person (Part B.1.) is not the Landowner of
Record, then complete, sign, date, and notarize this section:
, the Landowner of Record, authorize and give
permission to , the Financially Responsible
Party, to submit a draft erosion and sedimentation control plan and to
conduct the anticipated land disturbing activity.
Type or Print Name Title or Authority
Signature Date
, a Notary Public of the County of ,State of North
Carolina, hereby certify that appeared personally before me this day
and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this day of , 2
Notary SEAL My Commission Expires
PART B.
Person(s)or firm(s)who are financially responsible for this land-disturbing activity.
Covenant Village, Inc.
Name Contact Name for Inspection Reports
1351 Robinwood Road
Street and Mailing Address Email Address
Gastonia NC 28054
City State Zip Telephone Number
704-867-2319
Telephone Number Fax Number
1. If the Financially Responsible Party is not a resident of North Carolina, give the name and street
address of a North Carolina agent.
Name
Street and Mailing Address Email Address
City State Zip Telephone Number
2. 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
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3. 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.
Dale Melton CEO-Covenant Village,Inc.
Type or "nt Name Title or Authority
Slgnatur Date
I, Kr t C r ')c , a Notary Public of the County of C Thk? „r\,State of North
Carolina, hereby certifythat Cc ( � e. f '\ appeared personally before me this day
and being duly sworn acknowledged that the above form yips executed by him.
Witness, my hand and notarial seal,this 3 day of f-'. 2Cvt�,�.
ara: 3--i'; .'------ -c_J
Notary NOTARY P � ' My Commission Expires
Gaston County
North Carolina
MY Cammisalon Expire®April 3,2028
Erosion and Sedimentation Con rol Permit Submittal Checklist
Document Submittal Requirements
FRO has created a Citizens Self Service
Completed, Signed, and Notarized FRO n (CSS) Portal Account and the account has
l l Form (to be signed by person financially been verified
responsible for the project and no item
should be left blank, mark N/A if needed) n Copy of most current Deed for the site
I I Landowner of Record Authorization Letter I I Name and contact information of NC
(if the FRO is not the landowner of record) Registered Agent, if applicable
I Copy of Certificate of Assumed Name, if Complete set of Erosion Control Plans and
applicable ✓ Calculations (utilize remaining checklists to
ensure complete submittal)
Plans-Location Information and General Site Features
❑� Project Location 1 Roads, Streets
J• 1 North Arrow Scale
I I Adjoining lakes, streams, or other major
ri
drainage ways Property lines
✓ Legend 1 Existing Contours
✓ Proposed Contours 1 Limit and acreage of disturbed area
In
Planned and existing building(s) location n Planned and existing road(s) location and
and elevations elevations
✓ Lot and/or building numbers Land use of surrounding areas
Rock outcrops1 Seeps or springs
Wetland limits ✓ Easements
Streams, lakes, ponds, drainageways,
n
dams; also, any official wetland, stream, ✓ Boundaries of the total tract
and/or watercourse delineation report(s)
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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
ri under the 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.
nStockpiled topsoil or subsoil location(s) n Street profiles
Plans-Vegetative Stabilization
Planned vegetation with details of plants,
seed, mulch, fertilizer NOTE: Plan should
nAreas and acreage to be stabilized n include provisions for groundcover in
accordance with NPDES Construction
Stormwater General Permit NCG010000
It Specifications of permanent and Method of soil preparation
temporary vegetation
Plans-Site Drainage Features
Existing and planned drainage patterns
n (include offsite areas that drain through n Size of areas to be disturbed (acreage)
project)
nSize and location of culverts and sewers n Soils information (type, special characteristics)
nDesign calculations and construction for n Design calculations, cross-sections, and
culverts and storm sewers method of stabilization of existing and planned
channels (include temporary linings)
Design calculations and construction
details of energy dissipaters below culverts Soil information below culvert and storm sewer
ri and storm sewer outlets (for rip-rap ✓ outlets
aprons, include stone sizes(diameters)
and apron dimensions)
nDesign calculations and construction Name of receiving watercourse or name of
details to control groundwater i.e., seeps, ✓ municipal operator(only where stormwater
high water table, etc. discharges are to occur)
Plans-Erosion Control Measures
n Legend n Location of temporary and permanent
measures
nConstruction drawings and details for Design calculations and construction details
temporary and permanent measures for sediment basins and other measures
Maintenance requirements during I�I Person responsible for maintenance during
construction I I construction
Maintenance requirements and
F71responsible person(s)for permanent
measures
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Plans-Other Requirements
n
Narrative describing construction Narrative describing the nature and purpose of
sequence(as needed) the construction activity
Construction sequence related to
sedimentation and erosion control (include
Bid specifications regarding erosion I i installation of critical measures prior to
control initiation of the land-disturbing activity and
removal of measures after areas they serve
have been permanently stabilized)
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