NCC243400_FRO Submitted_20241106

0'"7'4. Gaston County
'a'' s �t Gaston Natural Resources Department
�1i!16 1303 Dallas-Cherryville Hwy. Dallas, N.C. 28034 Telephone. [phone]
40" 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 WA in blank)
MLA:
1. Project Name _Stowe YMCA Expansion
2. Location of land-disturbing activity
City Mt. Holly NC Highway/Street YMCA Drive
Latitude 35 76322 - Longitude-81 02009
3. Approximate date land-disturbing activity will commence September 25,2024
4 Purpose of development (residential, commercial, industrial, etc ) Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 4.75
6. Amount of fee enclosed $ 2000.00
7 Soil Erosion &Sedimentation Plan Filed? Yes_ Enclosed No X
X 8. Landowner(s)of Record (Use blank page to list additional owners)
a g5-6(4 dotm(ri rreosil41 91c4
Name
2L n 1- I R►b� &vivid ,2c:1 Name
Palling Addresses Address
I CRY State Zip rN State Zip
70 - VO- 1sS99
Telephone Number _I ( Telephone Number
9 Indicate Deed Book and Page where deed(s)or instrument(s)are recorded
Deed Book 2841 Page 9(4 _
Deed Book_ Page
10. Tax Map No. 212801 olcr.k _ Lot No.
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11. if the Financially Responsible Person(Part B.1.)is not the Landowner of
Record,then comp**, sign.dale,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 Flame Title or Autinrity
Signature Este
I, , a Notary Public of the County of ,State of North
Carolina. hereby certify that appeared personally before me this day
and being duty sworn acknowledged that the above form was executed by him,
Witness my hand and notarial set, this day of , 2
Notary SEAL My Commission Expires
PersOn(s)or rirrn(s1 who are liners-limy responsible kw this lama-eirstuatxng activity.
Name C• Name for Ins coon Reports
Street and Mal tng Address Entail •dress
ice. pS 70� -g1 a-i s 99
Stele Zip i 'ele�phone Number
$14-
Teiephone Number
1
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,
Made 21 I 1 64,.v,ip - d 4FAci5vitip, s ,104c4.. or.
Street a 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 ,nstruments for the financially responsible person) I agree to provide
corrected
_i`nformationn should there be any change in the information/fo provided herein
6�/IA 1�`�1Gti __ cti� —
X Type or Pnnt Name Tide or Authority
.,.--:ai. 44.0,..„, ii--R,o_____
Signature Date
I. EM.ii ( , a Natar ub is of 11�e County of E-t_ 0 , State of North
Carolina, F reby certify that �Q 'fit _appeared personally before me this day
and being duiy sworn acrcnowiedged that thgabove�rm was executed by him
Witness my hand a notarial seal, this day of Pi�}e tt , 2yyIL,�{
02
,:ry —01 , QN _
SEAL My Commission Expires t corkou ,p
OTgR y to
Erosion and Sedimentation Control Permit Submittal Checklist VQi:1C
o
L _- — Dut umenl Submittal Requirements tip xi,
FRO has created a Citizens Self Service
Completed Signed. and Notanzed FRO 0 1 (CSS) Portal Account and the account has
El
Form (to be signed by person financially t been verified
responsible for the project and no item 1
should be reit blank, mark NiA if needed) Copy of most current Ueea for the site
LiiLandowner of Record Authorization Letter (-i Name and contact information of NC
(if the FRO is not the landowner of record) L—J Registered Agent, if applicable
ri Copy of Certificate of Assumed Name, d Complete set of Erosion Control Plans and
1 Calculations utilize remaining cherklistc
I_J applicable I 1 ensure complete submittal)
Plans - Location Information and Genera! Site Features
tr—
Project Location l Roads. Streets
North Arrow 1 ~: Scale
Adjoining lakes, streams, or other major u property lines I
drainage ways U
1_1 } Legend Existing Contours
i �.�.. .
lProposed Contours — Limit and acreage of disturbed area i
0 Planned and existing building(s) location In Planned and existing roadfs)location and
and elevations — _ _ � J elevations
Il Il Lot endlo+building ni-imberc t and OSP of sirnni,inri,ng areas f
1Rock outcrops 7, . Seeps or springs _ 1
Wetland limits _ Easements
Streams. lakes. ponds, drarnageways. If i
dams: also, any official wetland. stream. n Boundaries of the total tract
and/or watercourse delineation report(s)
i-
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