NCC242618_FRO Submitted_20240827

/�oUNTp Gaston County
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Gaston Natural Resources Department
�� I •�1h 1303 Dallas-Cherryville Hwy. Dallas, N.C. 28034 Telephone: [phone]
t►��°n°z Soil Erosion & Sedimentation Control
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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 HEYCO
2. Location of land-disturbing activity
City DALLAS,NC Highway/Street 5134 APPLE CREEK PARKWAY
Latitude 35.31722 Longitude -81.1833
3. Approximate date land-disturbing activity will commence August 12th,2024
4. Purpose of development (residential, commercial, industrial, etc.) INDUSTRIAL
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 10.00
6. Amount of fee enclosed$4,000
7. Soil Erosion & Sedimentation Plan Filed? Yes Enclosed x No
8. Landowner(s)of Record (Use blank page to list additional owners)
MDTH Circuit LLC N/A
Name Name
1301 E.Pocket Road N/A
Mailing Address Mailing Address
Florence SC 28052 N/A N/A N/A
City State Zip City State Zip
864-454-2902 N/A
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deed(s)or instrument(s)are recorded
Deed Book 5476 Page 1945-1948
Deed Book N/A Page N/A
10. Tax Map No. 311883 Block Lot No. 8
Page 1

11. If the Financially Responsible Person (Part BA.) 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.
MDTH Circuit LLC William Keener(Bill)
Name Contact Name for Inspection Reports
1301 E.Pocket Road [e-mail]
Street and Mailing Address Email Address
Florence SC 28052 864-414-8580
City State Zip Telephone Number
843-454-2902 NA
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.
Bell Carrington Price&Gregg PLLC(Care of Brian Price)
Name
5550 77 Center Drive,Suite100 [e-mail]
Street and Mailing Address Email Address
Charlotte NC 28217-0700 864-312-5812
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
Page 2

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.
William Keener Vice President of Construction
Type or Print Name
/¢• Title or Authority
Gt/i/r.•4C K//) - _ 08-13-2024
Signature Date
Sowt11
Brian Nash , a Notary Public of the County of$ At bv.f`a} ,State ofNePth
Carolina, hereby certify that William Keener appeareapersonally before me this day
and being duly sworn acknowledged that the above form was exe uted by him.
Witness my hand and notarial seal, this /3 day of IQws5w3 . 2 O o2y•
,J. I.. /ZJ3///o a.9
Nota r qr4 SEAL My Commi ion E pires
r • BRIAN M.NASH
IONINR1OU',O MEOfIIMINCIAMMA
,,.0).n My Commission Empires 1213112021
""'rrN. Erosion and Sedimentatio Control Permit Submittal Checklist
Document Submittal Requirements
FRO has created a Citizens Self Service
Completed, Signed, and Notarized FRO (CSS) Portal Account and the account has
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) i/ Copy of most current Deed for the site
Landowner of Record Authorization Letter Name and contact information of NC
(if the FRO is not the landowner of record) Registered Agent, if applicable
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 i/ Roads, Streets
I I North Arrow 1/ Scale
Adjoining lakes, streams, or other major
drainage ways 1/ Property lines
Legend 1/ Existing Contours
%/ Proposed Contours i/ Limit and acreage of disturbed area
Planned and existing building(s) location ✓ Planned and existing road(s) location and
and elevations elevations
Lot and/or building numbers ,/ Land use of surrounding areas
Rock outcrops j/ Seeps or springs
4/ Wetland limits 1/ Easements
Streams, lakes, ponds, drainageways,
1/ dams; also, any official wetland, stream, 1,/ Boundaries of the total tract
and/or watercourse delineation report(s)
Page 3

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 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.
Stockpiled topsoil or subsoil location(s) Street profiles
Plans -Vegetative Stabilization
Planned vegetation with details of plants,
seed, mulch, fertilizer NOTE: Plan should
• Areas and acreage to be stabilized ./ include provisions for groundcover in
accordance with NPDES Construction
Stormwater General Permit NCG010000
Specifications of permanent and
✓ temporary vegetation ✓ Method of soil preparation
Plans-Site Drainage Features
Existing and planned drainage patterns
i/ (include offsite areas that drain through 4/ Size of areas to be disturbed (acreage)
project)
i/ Size and location of culverts and sewers i/ Soils information (type, special characteristics)
Design calculations and construction for 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
• and storm sewer outlets (for rip-rap ✓ outlets
aprons, include stone sizes(diameters)
and apron dimensions)
Design calculations and construction Name of receiving watercourse or name of
• details to control groundwater i.e., seeps, i/ municipal operator(only where stormwater
high water table, etc. discharges are to occur)
Plans - Erosion Control Measures
t/ Legend ✓ Location of temporary and permanent
measures
✓ Construction drawings and details for ✓ Design calculations and construction details
temporary and permanent measures for sediment basins and other measures
✓ Maintenance requirements during ✓ Person responsible for maintenance during
construction construction
Maintenance requirements and
✓ responsible person(s)for permanent
measures
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Plans -Other Requirements
✓ 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 ✓ 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)
Page 5