NCC243313_FRO Submitted_20241106

41PADA,
,,,\ AxAW EROSION CONTROL FINANCIAL RESPONSIBILITY FORM
ATTIVLJ INS'.
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No person may initiate any land-disturbing activity as defined in Chapter 159 of the Town of
Waxhaw Town Code prior to completion of this form, and an applicable and acceptable erosion
and sedimentation control plan has been approved by the Development Services Department.
(Please type or print)
Part I
Name of Project: •Waxhaw -8010713
Address where land disturbing activity will take place:
3210 S Providence Rd,
Waxhaw,NC 28173
Approximate date disturbing activity will commence: June 1,2024
Purpose of development(residential,commercial,industrial,etc.): Commercial
Total acreage of land to be disturbed or uncovered: 1.0649 ac
Amount of fee enclosed(show calculation): $550.00
N/A
N/A
Agent to contact should sediment control issues arise during land disturbing activity:
Name: Jay Banks
Address: 1927 South Tryon St. Suite 106
State: NC Zip code: 28203
Phone: [phone] Email: [e-mail]
Landowner(s):
Name: Madison Waxhaw Owner, LLC-CIO Ted Haley, Cameron Property Company
Address: 4064 Colony Rd.Suite 315
State: NC Zip code: 28211
Phone: [phone] ext 194 Email: thalevAcameronpropertvco.com
Name: N/A
Address: N/A
State: N/A Zip code: N/A
Phone: N/A Email: N/A
Indicate Book and Page where deed of the property where land disturbing activity will take place
is recorded:
Book: 07970 Page: 0082
Book: N/A Page: N/A
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WAXMAW
EROSION CONTROL FINANCIAL RESPONSIBILITY FORM
4,n.
Book: N/A Page: N/A
Book: N/A Page: N/A
Indicate tax map and parcel number of the property where land disturbing activity will take place
is recorded:
Tax Map: N/A Parcel: 06162005U
Tax Map: N/A Parcel: N/A
Tax Map: N/A Parcel: N/A
Tax Map: Parcel: N/A
Part II
Person(s)or firm(s)who are financially responsible for the land disturbing activity:
Name: JPMorgan Chase Bank, NA
Address: 1111 Polaris Parkway
State: Ohio Zip code: 43240
Phone: [phone] Email: [e-mail]
Name: N/A
Address: N/A
State: N/A Zip code: N/A
Phone: N/A Email: N/A
Name: N/A
Address: N/A
State: N/A Zip code: N/A
Phone: N/A Email: N/A
If the financially responsible party is not a resident of North Carolina, give the name and address of a
North Carolina Agent:
Name: CT Corporation System
Address: 160 Mine Lake Ct.Ste 200
State: Raleigh, NC Zip code: 27615
Phone: [phone] Email: [e-mail]
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 address of the registered agent.
Name: N/A
Address: N/A
State: N/A Zip code: N/A
Phone: N/A Email: N/A
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WAXIIAW EROSION CONTROL FINANCIAL RESPONSIBILITY FORM
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qift T e.abo e information is true and correct to the best of my knowledge and belief and was
revtewe
by me under oath. I agree to provide corrected information should there be any
change in the information provided herein. (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)
Name: Edwin Alvarez VP of JPMorgan Chase Bank,NA
Address: 1111 Polaris Parkway
State: Ohio Zip code: 43240
Phone: [phone] Email: [e-mail]
I, q11 ovir a e'Q° , a Notary Public of N+upR•.
ikQ�itCounty, North Carolina, do hereby certify that Edwin Alvarez VP of JPMorgan Chase Bank,N'rpers 4 nail,
Li PI appeared before me this day, and being duly sworn, stated that in his presenc- AS ' _
(signed) (acknowledged the execution of) the foregoing instrument.
Witness my hand and official seal, this the 11.44
1 day of lipri I , 20 LEI.
(Official Seal) 41(2
-
Notary Public
My commission expires 09120 , 20 Z C
e a,�T'-4ONY QUEIRO
�': !+otsry ,Ctic State D` 'orica
-'vim r :::r•T,..ur='i 75'a9
^'' My czfrm.Ex;,ires Sep 20.
3

NON-RESIDENTIAL
` ' ` EROSION AND SEDIMENT CONTROL INSTALLATION AND MAINTENANCE
AGREEMENT
,tee I i 1�9'1
, ANY LAND DISTURBING ACTIVITY LESS THAN I2,000 SQUARE FEET
3210 S Providence Rd,
STREET ADDRESS:
SUBDIVISION: Madison Park
LOT NUMBER: Lot#1
TOTAL ACREAGE: 1.06 ac
TOTAL ACREAGE DISTURBED: 1.07 ac
ANTICIPATED START DATE*: June 1, 2024
ESTIMATED COMPLETION DATE: Dec 31, 2024
PROPERTY OWNER: Madison Waxhaw Owner, LLC
TAX PARCEL NUMBER: 06162005U
*ALL EROSION AND SEDIMENT CONTROL MEASURES MUST BE IN PLACE PRIOR TO COMMENCING LAND
DISTURBING ACTIVITIES.
Option or a combination of options 1 &4 ,that best suit this site. Sediment control
measures will be installed as detailed.
Person or firm financially responsible for project:
Printed Name: Signat .
Edwin Alvarez VP of JPMorgan Chase Bank,NA
Company Name(if applicable)
JPMorgan Chase Bank,NA
Company President(if applicable)
N/A
Address:
1111 Polaris Parkway
Columnus,OH 43240
Phone Number: 305-579-9478
Email: [e-mail]
Site Drawing (Sketch of proposed site,including adjacent drainage and public right-of-way. Attach separate
document if needed.)
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• ZA D . NON-RESIDENTIAL
WAX AW EROSION AND SEDIMENT CONTROL INSTALLATION AND MAINTENANCE
E- IAA'1 AGREEMENT
4%),wiTO" ANY LAND DISTURBING ACTIVITY LESS THAN 12,000 SQUARE FEET
The Town of Waxhaw Erosion and Sediment Control Ordinance requires that anyone
conducting land-disturbing activity control sediment and provide adequate measures to retain
sediment at the disturbed site. The total disturbed area of the site includes any borrow or
waste areas that are used for the residential site, if the borrow or waste areas are not
currently permitted by the Town of Waxhaw or NCDEQ. Land-disturbing activities
include demolition and land clearing. Erosion Control measures must be installed in
accordance with the Town of Waxhaw Engineering, Standards and Procedures Manual. A
stabilized entrance pad of filter fabric, #5 washed stone and railroad ballast shall be located
where construction traffic will enter or leave the construction site onto a street. The
construction entrance shall be a minimum of twenty feet in depth and be a minimum of 12
feet in width. The filter fabric shall extend the full length and width of the construction
entrance. The construction entrance shall be maintained in a condition which will prevent
tracking or flowing of sediment onto streets or existing pavement. This may require periodic
top dressing with additional stone as conditions warrant and repair or cleanout of any
measures used to trap sediment.
Any sediment spilled, dropped,washed,or tracked onto streets must be removed
immediately. Any aggregate tracked into the street must be swept back onsite on a nightly
basis.
Following installation of these measures, please contact the Town of Waxhaw Permitting
Office at 704-843-2195 to schedule an erosion and sedimentation control inspection prior to
initiating any further construction activities.
Failure to install or maintain erosion control measures may result in penalties of up to $5000
per day.
If any indicated Erosion and Sedimentation Control (ESC) measures are not installed, a re-
inspection fee will be required.
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NON-RESIDENTIAL
WAX-HMV EROSION AND SEDIMENT CONTROL INSTALLATION AND MAINTENANCE
6:.IFAY AGREEMENT
ANY LAND DISTURBING ACTIVITY LESS THAN 12,000 SQUARE FEET
Choose from the following options or a combination of any of the following Options:
Option 1 Flow to the Rear Option 2 Flow to the Front Option 3 Flow to the Left
x x x x x
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14 M Lei -NC
Option 4 Flow to the Right
x
==>x
x
x
b
Y
x
X X Silt Fence
Construction Entrance
l > Direction of Flow
Vehicle Barrier
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