NCC231909_FRO Submitted_20230621

Co
° ',„4-, SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Division
RFATUR FS 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
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 has been completed and approved by the Lincoln County Natural Resources Division. (Please
type or print. 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 G&G Smiley: Campground RD
2. Location of land-disturbing activity: Latitude 35.540 Longitude -81.018 79314
Parcel Identification Number(PIN)3695978975&369598650Watershed Area N/A 79014
Highway/Street Address 7071 CAMPGROUND RD, DENVER NC
3. Approximate date land-disturbing activity will commence: MAY 25, 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): INDUSTRIAL
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 6.5 AC
6. Amount of fee enclosed:$ 1,400 .The Standard Permitting application fee of$200.00 per acre
(Rounded up to the next acre) is assessed without a ceiling amount(Example:9 acres total $1,800).The Express
Permitting application fee is a dual charge. The normal fee of$200.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount. In addition,the Express Permitting supplement is$250.00 per acre up to eight
acres, after which the Express Permitting supplemental fee is a fixed$2,000.00 (Example:9 acres total$3,800.00).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Local appointed person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name JEFF SMILEY E-mail Address [e-mail]
Telephone [phone] Cell# [phone] Fax# NA
9. Landowner(s)of Record (attach accompanied page to list additional owners):
G&G Smiley Investments, LLC [phone] NA
Name Telephone Fax Number
PO BOX 350 1333 NATURE PRESERVE TRAIL
Current Mailing Address Current Street Address
DENVER NC 28037 DENVER NC 28037
City State Zip City State Zip
10. Deed Book No. 2485 Page No. 740 most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s) if applicable: (attach accompanied page to list additional owners):
N/A N/A N/A
Name Telephone Fax Number
N/A N/A
Current Mailing Address Current Street Address
N/A N/A N/A N/A N/A N/A
City State Zip City State Zip

svx c,
t SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Division
RESOURCES 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
Part B
1. Person(s)or firm(s)who are financially responsible for the land-disturbing activity(Provide a comprehensive
list of all responsible parties on an attached sheet):
G&G SMILEY INVESTMENTS, LLC [e-mail]
Name E-mail Address
PO BOX 350 1333 NATURE PRESERVE TRAIL
Current Mailing Address Current Street Address
DENVER NC 28037 DENVER NC 28037
City State Zip City State Zip
Telephone [phone] Fax Number NA
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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A N/A N/A N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A N/A N/A N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(c) In order to facilitate Permitting, it is necessary to be able to contact the Engineer or other consultant who can
assist in providing any necessary information regarding the plan and its preparation:
SWARTZ DESIGN AND ENGINEERING, PLLC [e-mail]
Engineering Firm or other consultant E-mail Address
585 B AND T LN TAYLORSVILLE NC 28681
Current Mailing Address City State Zip
JEFF SWARTZ, PE [phone] [phone]
Individual contact person(type or print) Telephone Fax Number

=u0::r4. ` SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Division
va 115 West Main Street, Lincointon, NC 28092 704-736-8501 Fax:[phone]
FINANCIAL I sPO N s 1 BI L I..I., " i/ OWNERSHIP FORM
(d)Contractors and/or Subcontractors(person(s)or firm(s)engaging in the land-disturbing activity:
LB DELLINGER LLC N/A
Name of Person or Firm Name of Person or Firm
4087 NC HWY 10 E N/A —
Current Mailing Address Current Street Address
CLAREMONT NC 28610 N/A N/A N/A
City State Zip City State Zip-- N/A
Individual contact person(type or print) Individual contact person(type or print)— --
Telephone [phone] Telephone N/A
Fax Number -- _—__— Fax Number N/A
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 by any change in the information provided
herein and any other associated documents.I understand that all documents that are associated with this project and
project number are parts of the complete project document.
Permission to Enter on Land
I certify that I am authorized to grant and do in fact grant permission to the Natural Resources Erosion Control Inspector
and his agents to enter on the land in question in connection and/or related to this permit.
—fit: ca,,,. a.... C-7,1Z.
Type or print nam Title or Authority
3a 2'3
Signature Date—
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State of North Carolina, hereby certify that LT _appeared personally before
me this day and being duly sworn acknowledged that the above form w s executed by him.
Witness my hand and notarial seal,this YO day of ,/qe..'.e, 20_
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