NCC232499_FRO Submitted_20230818

I.
` Land-Disturbing
t't t n,t II A hti c c,t II`r I Permit Application �eu.LANS ( , WO
**The mailing and street address of the principal place of business for the person/entity financially responsible and
the land owner(s)must be provided.A P.O.hos is NOT acceptable as an address.
"If the financially responsible party is different from the current land owner,an agreement signed by both parties
must he provided allowing the financially responsible party to conduct the land-disturbing activity on the property.
This agreement is provided on page 3 of this application and must be completed in its entirety.
PROJECT NAME: Governors Club-Lot 610 ATE: 7/C‘/L7
.
ADDRESS OF PROJECT: I //L fl?4t ), C /Ar I/,!x ',"'/1
I.ATITUDE/LONGy'l E OF PROPERTY AT SITE ENTRANCE: 3S Giro _- DI.6r•/00
PARCEL#(S): C 0
TOTA1.DISTURBED ACRES or�QUAR�!�1�'�� _-_45
PURPOSE OF ACTIVITY: /jeq/ (or►r, 1�(adv,,,,,_
FEE AMOUNT SUBMITTED: RIVER BASIN:CAPE FEAR
"LANDOWNER(S)OF RECORD(attach page to list additional owners)
Please provide a complete list of partners,managing members and registered agents if the responsible entity or
land owner is a group pf individuals.corporate organization or nitName: ki U "V A- [ G f- Phone: ( 2 r 'f'r'/"
Address: 9-7'j0 `3 � � � E-Mail: JC�J e �1Z:t•:<,'"
**FINANCIALLY RESPONSIBLE PARTY(applicable only if different from pr ` vowner)
Name: Phone:
Address: E-Mail:
Signature:
NORTH CAROLINA AGENT(applicable only if either owner or financially responsible party does not
reside in North Carolina)
Name: Phone:
Address: E-Mail:
Signature:
ENOINEER`SURV-YOR EROSION CONTROL
Company Nivite; thik,TA1S Person to contact should erosion&sediment
Address: el�t .-�_ control issues arise dti 'ng lj,gd- isl whine activity:
u `� ,A.. t �'1"^`, Contact Person: tft, f
Contac ets S Company m :
Phone: ��-1`.S j-2 404 Phone: °I( tJ- l
E-Mail: (xXlCl✓-lw i ytct a 4y.. - _ s4.AE-Mail: tc i %(,T C e �Jt.4, I.�rA�
�— 1 9
Page 2 of 3
ANTICIPATED START DATE: ANTICPATED END DATE:

Soil Erosion and Sedimentation Control
C_HATHAM C.OlIN'1'Y
IA 46" ' " ' ^w r" ' ' ` Financial Responsibility/Ownership Form
NOT REQUIRED TO RE_ COMPLETED 1•'OR RESIDENTIAL LOT PERMITS.
PLEASE READ THE FOLLOWING INFORMATION:
I)This section must be signed in the presence of a Notary.
2)this form must be signed by the properly owner Wan individual.'loomed by a company or eurpou0 oo.this form must be signed In Alen officer.
director.partner.attorney-in-fact,or other person with authority to execute instruments fur the corporation and accompanied by a complete list of all
partners.managing members and registered agents oldie company or corporation.
3) this form must also be signed by the financially responsible party and NC agent(if-applicable).Same provisions of N 2 above apply.
.1)If the landowner and financially resp.muihle party are different.the completion and signing of this page shalt serve as documentation
acknowledging the landowner consents to and authoriAes the financially responsible party to undertake the proposed land-disturbing actin ity on the
landowners tracts)of land identified on this application.
5)the information pros ided on this form is true and correct to the best of my knowledge and belief and was provided by me while under oath.
61 All Land-Disturbing permits arc valid thr lip to(2)years from the date of issuance. If circumstances warrant,the permit may be extended for
(2)years 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. II the permit is revoked, all other permits and approvals roc withheld until
the property is once again in compliance with Chatham County regulations. Also,upon written notice,a civil penalty(fine)can be instigated
against the property owner and or additional financially responsible party(if any)for violations of the Chatham County Soil Erosion and
Sedimentation Control Ordinance.This pintail!:is up to 55000.00 per violation per day and is assessed daily for every day the property is in violation.
Interfering with or hampering an inspection can result in a civil penalty without written notice.
OWNER OF PROPERTY:
Name and Title: IGC
Company(if applipgb•� : •
Signature:r ..
FINANCIAi.LY RESPONSIBLE PARTY (applicable only if different from property owner):
Name and Title:
Company: _
Signature:
NORTH CAROLINA AGENT(if any):
Name and Title:
-- -
Company:
Signature:
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i."PAAI/C'L L J Ctrs ,a Notary Public of MONnhdu1 if
of /V r.) -`��.5 ry _County in the state
do hereby certify that V/IZC/A! p9 GU y personally
appeared before me this day and under oath acknowledged reading the information above and acknowledged that the
above form was executed by him or her.
Witness my hand and official seal,this the o T day of TUa r ,20 Z3
Notary Public
My comfit i op�a EISS
7-3 _ (SEAL)
NOTARY PUBLIC
STATE OF NEW JERSEY
ID#70262 Page 3 of 3
MY COMMISSION EXPIRES NOVEMBER 28.2023