NCC221398_FRO Submitted_20220407

CFEA'1"HAM CC7l.It�i"1"Y"
u rt a n c- w as . a � �� .•
FINANCIAL RESPONS]BI1.ITYlOWNERSHIP FORM
DEPARTMENT ON SOIL EROSION & SEDIMENTATION CONTROL
A Land -Disturbing Permit must he obtained before initiating am land-disturhinv aclivily which
xvill exceed I I I acre I41,560 square feel). A Land -Disturbing Pertnii Application. this Financial
Form, an Erosion and Sedinu•nt Control Plan" plan review tee. and permit fec• should be subirtitted
30 davit prior to the Planned cointnencemrnr of the land-dicnubing activity.
The above information should he submitted to: .IiIII NV iHis
Soil Erosion & Sedimentation Control Dept.
P.U. Bo\ 130- NO Bast Street
Pittsboro. N(' -17? 1'-0130
Please t pe or print the following information:
Date: ; I 1 _'
Name of Proiect: Alnchrie
Location o!"Project: j?I Ri%crine Dh%c I' ,•i',.,. vc
Acreage to he disturbed: -1 2j 1111)
Purpose of actin it%: . ' ,� •yid •nti• I Sjuglc F• mile DNvjlirn,
Landowner(s1 of recnrd:
Name: Kirk n, o0iie Dame:_
Address: 1„ ,ANuK v t 11 %y Lc(,',, Address:
Can. NC'_ 10
Telephone: Home 011)-4ul,,t,0114
Off ice
Fax
E-Mail m,• Iair asrcliuirn4-con,
Telephone: Home
Office
Fax
E-Mail
Indicate Book and Palle w here deed or instrument is filed.
Book
PIN#
„a'-t 15f a 1-11502_ PalTe
Thy information pro%ided on this lorin is true and correct to the bcsl of tm l.nuwlcdgc and beliel and was
provided h-, ntc while under oath- Phis foilli must he signed by he ttroreny owncr if an individual If
nnrord by a company or corporation. this rnnsi muss lie signed by all officer- Aireciur. banner. attorney -in-
tact, or other person with authority to evecutc instrtuments for [lie corpt,ratl(an. If the I'C'W t flin incialiy'
resnonsihlc is not a resident of nuttli Curolina, a Nonla Carolina aveut tttusl be desinnated if sotnronc
other than the oo4ncr is financially responsible. their si n:uure i, rccluircd b0ow ako
KiiK ht,•.l,r:
Name of individual
Title and Niutae of Can�pany p
/`�
Otiner's SiOniuure
NC agent's %innaiure (If applicable)
Additional Financially Responsible
Party (It applicable)

PLEASE READ THE FOLLOWL G INFORNUTION:
All Land-DlSlUrbin, permits are valid for up to (' 1 years from the date (if issuance. If
circumstances warrant it, the permit may be extended for 111 year per the conditions of
the. Chatham County Soil Erosion and Sedimentation Control Ordinance. Upon written
notice. the Land -Disturbing permit may be revoked for failure to comply with the
Ordinance. If the permit is revoked. Lill other permits and approvals are wi¢hheld until the
property is once again in compliance with Chatham County regulations- Also. upon
written notice. a civil penalty t noel can he instigated against the property owner and/or
additional financially re�,ponsihle party of any) for violations of the Chatham County Soil
Erocion.and Sedirtientation Control Ordinance. 'this penalty is Lip to $5000U) per day
and is assessed daily for every day the property is in violation. hitcrti rin_ with or
hampering an in pection can result in a civil penalty %vithout written notice.
s'I-ATE OF r'VA- U�t�wEt s 1GV_1T rRk
CO . TY OF IU44M
1, t a Notary Public of said Count% and State. do
hereby cer v that. t4,e- personallN appeared
before me this day and under oath acknowledged reading the information above and
acknowledged that the allove limn was executed by him or her.
Witness my hand and official seal, this the le day � .'fkg--�'
y�
o[ary =rham
My Commission Expire,__aan Long
tytSE:�L) n
STATE OF
COUNTY OF
(additional financially responsible party)
1. . it Notary Public of said C('Unly :uid State. do
hcrcby certify that lxrsonally appeared before me this
day and under oath acknowledged reading the information above and acknowledged that
tile above limn wat csecutcd by hire or her.
Witness my hand and official seal, this the dad ol- .'_0_
My Commission Expires:
tSEALt
Notary Public