NCC231027_FRO Submitted_20230418

FINANCIAL RESPONSIBILITY!OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by the
Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office.(Please type or print and,if the question is not applicable or the e-mail and/or fax
information unavailable,place N/A in the blank.)
Part A
1. Project Name The Lakes RV and Cabin Resort
•
Jones _City or TownshipMaysville
2. Location of land-disturbing activity: County � .,.�. t;lf .. ..�,_
Highway/Street 10th Street Latitude. 34.8986 Longitude -77.2297
3. Approximate date land-disturbing activity will commence: January'2023
4. Purpose of development(residential,commercial,industrial, institutional,etc.): Residential
5. Total acreage disturbed or uncovered(Including off-site borrow and waste areas): 25.1
6. Amount of fee enclosed: The application fee of Simon per acre(rounded
up to the next acre)is assessed without a ceiling amount (Example:a 9-acre application fee is$585).
7. Has an erosion and sediment control plan been filed? Yes X No . Enclosed
B. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name James Maiden E-mail Address [e-mail]
Telephone, (910 938-.5900 Cell# Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
The Lakes RV&Cabin Resort, LLC [phone]
Name Telephone Fax Number
166 Center Street 166 Center Street
Current Mailing Address Current Street Address
JACKSONVILLE NC 28546 .JACKSONVILLE NC 28546
City State Zip City State Zip
10. Deed Book No. . .314_ . . Page No_ 339 Provide a copy of the most current deed.
Part B.
1. Company (les) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) if the company or firm is a sole
proprietorship the name of the owner or manager may be fisted as the financially responsible party.
The Lakes RV& Cabin Resort, LLC [e-mail]
Name .-.- E-mail Address
166 Center Street
166 Center Street_„ .,.�
Current Mailing Address Current Street Address
Jacksonville NC 28546 Jacksonville NC 28546
City State Zip City State Zip

Telephone_ (910) 93$-5900 — Fax Number
2. (a)If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent
Name E-mail Address
Current Mailing Address Current Street Address
State Zip City State
City zip
Telephone Fax Number „
(b) 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 name and street address of the Registered Agent:
_ — —
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone _,, Fax Number - _.._.
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
the 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.
James Maides Manager / __
James � �.�..®.. Title orAufhorit
Type or pn#nam0 see �, "" Y
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I,.C4PIe,.r t ( WE' lcl--. ,a Notary Public of the County of Qmtov.l
State of North Carolina, hereby certify that_ ?' 1e" _ t ,2 - --_appeared
personally before me this day and beirt ty sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal,this i day of a _, ,20
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