NCC232382_FRO Submitted_20230922

Orange County Planning & Inspections Department
ORANGE COUNTY 131 W. Margaret Lane, Suite 200, Hillsborough, NC 27278
NORTH CAROLINA 919-245-2575 or pianningappsorangecountync.gov
Land Disturbance Permit (LDP) Application
Please refer to instructions and checklist in completing the following application.
If completing by hand, please use black or blue ink.
Date: 7/17/23 Case Number:
Check all that apply: 7 Erosion Control Plan
Stormwater Permit
Stormwater Management Plan
General Submittal Information
Name of Project: Seagondollar & Hailey Residence
Parcel ID Number (PIN): 9844-79-4486 Planning Jurisdiction: Orange County
Size of Tract: 3.14 acres Area Disturbed 0.48 acres
Fees — Section Completed by Staff
Fee Amount
Erosion Control Plan Review 440.00
Required with Application $
Land Disturbing Permit
Optional with Initial Application $
Stormwater Management Plan Review
Orange County Planning Jurisdiction Only
Required with Application $
Total $
Approximate date land disturbance will begin: August 2023
Contact Information
Landowner(s) of Record (Use additional pages if necessary and attach to application):
Name: Mark Seagondollar Name: Meredith Hailey
Street Address: 509 Findhorn Lane Street Address: 509 Findhorn Lane
Current Mailing Address: Current Mailing Address:
509 Findhorn Lane 509 Findhorn Lane
City: Wake Forest City: Wake Forest
State: NC Zip: 27587 State: NC Zip: 27587
Phone: [phone] Phone: [phone]
Email: [e-mail] Email: [e-mail]
Page 1 of 4

Contract Purchaser (if applicable) (Use additional pages if necessary and attach to application)
Company/Organization: Company/Organization:
Contact Person: Contact Person:
Street Address: Street Address:
Current Mailing Address: Current Mailing Address:
City: City:
State: Zip: State: .Zip:
Phone: Phone:
Email:Person(s) or Firm(s) Financially Responsible for this Land Disturbing Activity
Company/Organization: Corn pany/Orga nization:
Contact Person: Contact Person:
Street Address: Street Address:.
Current Mailing Address: Current Mailing Address:
City: City:
State: State: Zip:
Phone; Phone:
Email: Email;
Registered Agent(if any) for the Person(s) or Financially Responsible Party
(NOTE a North Carolina agent is required if the appiicant is not a resident of Noith Carolina)
Name: Mark Seagondollar Name:
Street Address: 509 Findhorn Lane Street Address:
Current Mailing Address: Current Mailing Address:
509 Findhorn Lane
City: Wake Forest City:
State: NC Zip: 27587 State: Zip:
Phone: [phone] Phone:
Email: [e-mail] Email:
Page 2 of 4

Additional Project Information
Project Description (detail the scope of the project and nature of land disturbance):
The Seagondollar property is currently vacant/undeveloped land that is zoned for single-family
residential use. Proposed improvements include construction of a 42' x 64' single-family home, a
proposed 30' x 45' shop, utilities, and associated gravel driveway. Clearing/disturbed limits and location
of site elements are shown on the attached Erosion Control Plan.
Plans Prepared by:
Name of Person/Firm: MLA Design Group
Contact Person: Paul Fidishun
License Number: 643
Mailing Address: 120 Club Oaks Court, Suite 100
City: Winston-Salem State: NC Zip: 27104
Phone: [phone] Email: [e-mail]
Page 3of4

pagicatio.n and Signatures Wag=
Signature and Witness: The above information is true and correct to the best of my knowledge and
belief and was provided by me while under oath.
S26-c vr1 51 aP
Signature of Financially Responsible Party Type or Print Name Legibly
r o b a,AY 1yt,C i ) L 2 2-3Title or Authority Date
I, - \\\� a Notary Public of the County of Yy 0.01 �)
here y certify that MIMI'\ ll r\M-ONSQc4,vr d,c)LcX- personally before me this day and
under oath acknowledged that this Application for Erosion Control Plan Approval, Stormwater
Management Plan Approval, and Land Disturbing Permit/ Statement of Ownership and Financial
Responsibility was executed by him or her.
Witness my hand and notarial seal, this lDay of \A
Si. \4$V262-5-
,44 efof ry My Commission Expires
e 0 S.
t • ` 1 r nAtizimowledgement
ge the above information and parties referenced herein have been granted
perr4fa it vpflli duct development activity on referenced property of which I own.
Signature(-Of Property Owners Type or Print Name Legibly
l�I > w ,,} 207:3
Date
I, c U,\\tiA a Notary Public of the County of 6/4,-(111 ,vc
hereby certify that t-Qa,Aku3intlkul SQayndollar 1 mih rd‘ ersonally before me this day and
under oath acknowledged that this Application for Erosion Control Plan Approval, Stormwater
Management Plan Approval, and Land Disturbing Permit/ Statement of Ownership and Financial
Responsibility was executed by him or her.
Witness my hand and notarial seal, this Iay of \ off, ,
( Ootho
Signature ot‘Nti ►,��, My Commission Expires
t oily
SEAL ?` 4) ztz
.° .°'
G%%` Page 4 of 4