NCC230127_FRO Submitted_20230131

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
No person may initiate any land -disturbing activity o� ane ar more acres as covered by the Acfi before this
form and an acceptable erosion and sedimentafian control plan' have been campleted and approved by the
Land'
Quaiity Secti on, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regions{ Office. (Please type -or print and, if the question is not applicable or the e-matl address
or phone number is unavailable, place N/A in the.blank.)
Part A.
'I .
Project Name Rjqgeline
Glarnging
RV Park
2.
Location of land -disturbing
activity:
CountyTransylvania City or Township Pisgah Forest
Highway/Street 130 Kennedy Dr. Latitude(decirnal degrees) 35.226063 Longltudetdec»naidegree57-82•60689
34. Approxi.m'ate date. I"and-disturbing activity ►nri!! cammence: Dec 15,_ 2022
4. Purpose' of development (residential, commercial, industrial, institutional, etc.}: Commercial 1
Recreation.
5. Total acreage disturbed or uncovered (including off -site harrow and waste areas): 8.0
6. Arnount0f fee enclosed $2,800.00 .The Express. Permitting application fee is a dual
charge. The normal fee of $100-00 per acre (rounded up to. the next acre) is assessed without a
ceiling amount... In -addition, the Express. Permitting supplement is $260 per acre 'up to eight acres,
after which the Express Permitting supplemental fee- is a fixed $2,000.00 (Example". 8.10-acre
application fee i's $2,900). Checks should be addressed to NCDEQ.
T Has an erosion and sediment control plan been filed? Yes ❑ . Enclosed Z No El
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ter McCracken
Phone: office #
30-904-5323
E-mail Address tmccracken520(a),.qmaJ1.corn
Mobile # [phone]
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9. Landowner(s) of Record.(attach accompanied page to list additional owners):
Ridg.eline Glam in
Name
LLC
330-904-5323
Phone: Office #
330-904-5323
Mobile #
130 Keened Dr 130 Kennedy Dr EEEEEEEWV�
Current Mailing Address Current Street Address
Pisaah Forest NC 28768 Pisgah Forest NC 28768
City State zip -.City State Zip
10. Deed Book.No.- 00963 Page No. 0148 Provide a copy of the most current died.

IV
Part B.
1. Company(ies)- who are financially responsible for. the land -disturbing activity (Provide a comprehensive
list -of all responsible. parties on accompanied page.) If the, --'company is a sole proprietorship or if the
landowner(s) is an in.dividUal(s), the' name(s) of the owner(s) may be listed as the financia'lly responsible party(ies)-
Rid eline Glamping, LLC
Company Name
tmccracken520
E-mail Address
mail.com
130 Kennedy Dr 130 KennedyDr
Current Mailing Address C.urrent Street Address
Pisgah Forest NC 28768
City State Zip
Phone: Office # 330-904-5323
Pisgah- Forest NC 28768
City State Zip
Mobile # [phone]..'
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this farm
the landowners signed and dated written consent far the app��cant to submit a drat erosion and
sedimentation control plan and to conduct the anticipated land disturbing activity,,
2. (a)'If the Financially Responsible Party is a domestic company -registered an the NC Secretary of State
business registry, give name and street address of the Registered Agent:
McCracken., Terry
Name of Registered Agent
130 Kenned Dr
Current Mailing Address
tmccracken520
E-mail Address
mall.com
130, Kennedy Dr
Current Street Address
PisPisgahForestkwffnw� N C 28768 Pisgah Forest NC 28768
City State Zip City State Zip
Phone: Office # 330-904-5323 Mobile # [phone]
Name of Individual to Contact cif Registered Agentis a company}
fib} if the- Financially Responsible Party is not a resident of North Carolina, give name and street address
of the'designated North Carolina agent who is registered an the NC Secretary of State business registry:
Name of Registered. Agent
Current Mailing Address
City State Zip
Pho'ne: Office #-
E-mail Address
Current Street Address
City State Zip
Mobile #
Name of Individual to Conta' ct cif Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name
under which the company is Doing Business As. If the Financially -Responsible' Party is an individual,
General Partnership, or of ter company not. registered and doing business under an assumed name,
attach a copy. of the Certffiqde of Assumed Name.
1
Company DBA Name
(d) ! f order to facilitate Express Permitt'j'ng, it is necessary to b. bl a to contact the engineer or other
consu Itant w ho ca n ass I st i n p rovid i ng a ny n aces a rY i nformation reg a rd i n g th a plan -a n its preps ration
Engineering firm. other consultant
Individual contact person(type or print)
E-mail Address
Phone: Office # Mobile
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(s) or his attorney -in -fact, or if not an individual, by' an officer, directory partner, or
registered agent with the authority to execute instruments for the . Financially. Responsible Party). 1
agree to provide, corrected' information shouldthere be any. change in the information provided
herein.
f-j-.qA
Type. or pAnt game
17 Iw� el ht.CT-
Title or AuKority
Date
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a Notary Public of the County of
State of North Carolina hereby certify that � Y �
personally before me this day and being duly sworn acknowledged th
executed by him/her.
Witness my hand and notarial seal, this ,day ofCt rc � , 20
SHARA S CONLEY
,NOTARY PUBLIC
TraJ§yl vania County
State of North Carolina
My Comm. Expires March 1, 2027
J%
Notary
My cammissian expires
appeared
the above form was
0 1.5 20Z004-