NCC216820_FRO Submitted_20211213

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
Ohana RV Park
2. Location of land -disturbing activity: County
Highway/Street Fulchers Landing Latitude 34.5599
Onslow
3. Approximate date land -disturbing activity will commence:
City or Township Sneads Ferry
Longitude -77.3870
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (Including off site borrow and waste areas): 1.7
6. Amount of fee enclosed: $ 130.00 . The application fee of $65.00 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 No X Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jonathan Wall
E-mail Address [e-mail]
Telephone [phone]
Cell # _ Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Jonathan Wall
[phone]
Name
Telephone Fax Number
370 Barnes Ridge Drive
370 Barnes Ridge Drive
Current Mailing Address !'
Current Street Address
Clayton NC
27527 _Clayton NC 27527
City State
Zip City State Zip
10. Deed Book No. 4847 _
Page No. 507 Provide a copy of the most current deed.
Part S.
1. Company (ies) 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 listed as the financially responsible party.
Jonathan Lee Wall
7onathanwall9l dZgImail rnm
Name
E-mail Address
307 Barnes Ridge Drive
307 Barnes Ridge Drive
Current Mailing Address
Current Street Address
Clayton NC
27527 Clayton NC 27527
City State
Zip City State Zip

Telephone [phone] 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
Current Mailing Address
City State Zip
Telephone
E-mad Address
Current Street Address
City State Zip
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
Current Malling Address
E-mail 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 -fad, or if not an individual, by an officer, director, partner, or registered agerdiMth
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.
Jonathan Lee Wall
or print name
Owner
Title or Authority
Date
I, _qgI L---I a Notary Public of the County of Cnun4
State of North Carolina, hereby certify that J D n O,l V-,cky, \/� cd A appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed bX�f�li�ir,�
�� C . �i
Witn*V',;p�'�and a9figb jai seal, this day of _Q G1ti -' , 20 _ 2.-- k_
N ry
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My commission expires ®C,�-p Idea- I l , 2mo