NCC243402_FRO Submitted_20241105

01:1NTl. Gaston County
II' ' Gaston Natural Resources Department
1.1111 1303 Dallas-Cherryville Hwy. Dallas, N.C. 28034 Telephone: [phone]
41 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)
1. Project Name Village at Parkside
2. Location of land-disturbing activity
City Gastonia Highway/Street Inwood Hill Or.&Port Richmond Ave.,Gastonia,NC 28056
Latitude 35.222871 Longitude -81.186160
3. Approximate date land-disturbing activity will commence 08/2024
4. Purpose of development (residential, commercial,industrial,etc.) Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas) 3.20 acres
6. Amount of fee enclosed $$1600
7. Soil Erosion &Sedimentation Plan Filed? Yes Yes Enclosed No
8. Landowner(s)of Record(Use blank page to list additional owners)
Adams Homes AEC,LLC
Name Name
100 W.Garden St.2nd Floor
17. i ng7d3ress Alaliing A3dress
Pensacola FL 32S
State Zip r'7 State Zip
828-275-4907
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deed(s)or instrument(s) are recorded
Deed Book 5212 _ Page 2424
Deed Book _ Page
10. Tax Map No. Block _ Lot No.
Page

11. If the Financially Responsible Person (Part B.1.) is not the Landowner of
Record, then complete, sign, date, and notarize this section:
I, , 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
.Z'1,:/-1-- (;1/441T--
Typ or Print Na Title or Authority
S. a Date
I, F \ v �C� a Notary Public of the County of lC)l — State of North
Carolina, hereby certify that1-4.- --►29t0- 1 appeared personally before me this day
and being duly sworn acknowledged that the above form as executed by him.
Witness my hand d otati�l seal,this o�,�day c 2c7o1A-P
/ P 12-0.= $
ary SEAL My Commission Expires
Person(s)or firm(s)who are financially responsible for this land-disturbing activity.
Adams Homes AEC,LLC Mac Gourlay
Name Contact Name for Inspection Reports
100 W.Garden St.2nd Floor 3401 St.Vardell Ln.,Ste.B
'Srreer a rara"I Il'ng Address Email Address
Pensacola FL 32502 828-275-4907
ri7 State Zip Telephone Number
678-725-3272
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.
National Registered Agents,Inc.
Name
160 Mine Lake Court,Suite 200 Privacy Reasons
Street and Mailing Address Email Address
Raleigh NC 27615 Privacy Reasons
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.
a
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 4corre t d information should there be any change in the information provided herein.
Type or Print Name Title or Authority
�,2
Signature Date p — F
I, Uif a Nota Public of the County of `-'�c $ �—' State of North
Carolina, hereby certify that ¶ ---- appeared personally before me this day
and being duly sworn acknowledged that the above for was executed by hi
Witne a d and notarial seal,this a-- — day of 4`, 2
Notary SEAL My Commission Expires
Erosion and Sedimentation Control 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
ZForm(to be signed by person financially been verified
responsible for the project and no item
should be left blank, mark N/A if needed) Copy of most current Deed for the site
❑ Landowner of Record Authorization Letter 1-7 Name and contact information of NC
I I(if the FRO is not the landowner of record) Registered Agent, if applicable
n Copy of Certificate of Assumed Name, if Complete set of Erosion Control Plans and
I I applicable 111 Calculations (utilize remaining checklists to
ensure complete submittal)
Plans-Location Information and General Site Features
H —,
Project Location 1 Roads, Streets
North Arrow 1 Scale
❑ Adjoining lakes, streams, or other major
drainage ways ri
Property lines
Legend ✓ Existing Contours
✓ Proposed Contours I Limit and acreage of disturbed area
I I Planned and existing building(s) location n Planned and existing road(s) location and
and elevations elevations
1 Lot and/or building numbers 1 Land use of surrounding areas
Rock outcrops Seeps or springs
^ Wetland limits 1 Easements
Streams, lakes, ponds, drainageways,
ndams; also, any official wetland, stream, n 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
Elunder 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 include provisions for groundcover in
accordance with NPDES Construction
Stormwater General Permit NCG010000
nSpecifications 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 ❑� Size of areas to be disturbed (acreage)
project)
ElSize and location of culverts and sewers n Soils information (type, special characteristics)
nDesign 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
ndetails 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
ndetails to control groundwater i.e., seeps, El municipal operator(only where stormwater
high water table, etc. discharges are to occur)
Plans-Erosion Control Measures
❑ 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
3 Maintenance requirements during n Person responsible for maintenance during
construction construction
Maintenance requirements and
I I responsible person(s)for permanent
measures
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Plans-Other Requirements
nNarrative 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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