NCC232254_FRO Submitted_20230728

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.••: Gaston County
i Gaston Natural Resources Department
G/ 1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
♦�,totei Soil Erosion & Sedimentation Control
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Financial Responsibility/Ownership
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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 Belmont Abbey Multipurpose Track and Field
2. Location of land-disturbing activity
City Belmont Highway/Street Wimmer circle
3. Approximate date land-disturbing activity will commence 07/01/2023
4. Purpose of development(residential, commercial, industrial, etc.) track field and event area
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 7.65 ac.
6. Amount of fee enclosed $ 2,400.00 (8.0 x 300.00/ac)
7. Soil Erosion &Sedimentation Plan Filed? Yes x No
8. Landowner(s)of Record (Use blank page to list additional owners)
Southern Benedictine Society of North Carolina, Inc.
Name Name
100 BELMONT MT HOLLY RD
Mailing Address Mailing Address
BELMONT NC 28012
City State Zip City State Zip
704.461.6736
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deed(s) or instrument(s)are recorded
Deed Book 265 Page 55
Deed Book Page
10. Tax Map No. 217518 Block Lot No.
Page 1

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PART B:
1. Person(s)or firm(s) who are financially responsible for this land-disturbing activity 1
Southern Benedictine Society of North Carolina, Inc.
Name Name
100 BELMONT MT HOLLY RD
Mailing Address Mailing AddressIt
BELMONT NC 28012
City State Zip City State Zip F
704.461.6736
Telephone Number Telephone Number
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street t
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address of a North Carolina agent.
Name ,
Mailing Address Street Address rt
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City State Zip Telephone Number
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3. If the FinanciallyResponsible Partyis a Partnershipor otherperson engagingin business under
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an assumed name, attach a copy of the certificate of assumed name. If the Financiallyt.
Responsible Part is a Corporation give name and street address of the Registered Agent.
Name
Mailing Address Street Address E
6-
City State Zip Telephone Number
4. 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 i
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agree to provide corrected information should there be any change in the information provided
herein.
Kerry O'Leary Project Manager }
Type or Print Narpe--, Title or Authority
JGlt� � a , �oa3
Sign ure Date
I, Cc1e( e-LtC1rkl r a Notary Public of the County of State of North
Carolina, hereby certify that Prthat 0/LeaN appeared pers nally before me this day
and being duly sworn acknowledged the abpve fbrm was executed by him,
Witness y hand and notaria eal, this ( day of CT(A nE , 20,RD
otary SEAL My Commission Expires
1 File: Financial Responsibility-Ownership Form.mw t
Page 2
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