NCC220798_FRO Submitted_20220217

/.S
Land -Disturbing
Permit .Application
Please complete both pages of this form and return to: For Office Use:
Physical Address Mailing Address
80 East St. PO Box 548
Pittsboro, NC 27312 Pittsboro, NC 27312
Phone: [phone]
Please see PERMITTING FLOW CHART to determine which permit and plan requirements apply to
Your project and then check one of the boxes below:
"EkLand- Disturbing Permit. The following items are required
q red to obtain this permit. completed
application, plans, and fees. Land -Disturbing Permit applications must include all parcels/lots on
one application with the total amount of disturbance for all parcel/lots. All clearing and disturbance
must be included when calculating disturbed area.
Fee Requirements:
Permit Fee: $250ldisturbed acre
Plan Review Fee: $250/disturbed acre
Fees are rounded up to the next whole acre.
Exam le: 1 acre or less is $500, 1.01-2 acres is $1,000, and 2.01-3 is $1,500.
Plan Requirements-
DeskR Plan: submit (I) copy of an erosion control plan completed & sealed by a professional land
surveyor, professional engineer, or registered landscape architect. This plan must meet the criteria of the
Chatham County Erosion Control Plan Review Checklist and include all applicable construction details.
These can be found on the Chatham: County Watershed Protection website, on the Erosion Control
web a e. This plan must satisfy all local, state, and federal minimum plan requirements,
General Plan: submit (1) copy of site plan along with the Chatham County Residential General Plan. Site
plan is not required to be completed by a design professional. The Residential General Plan can be found
on the Chatham County Watershed Protection website on the Residential Construction webpage. Indicate
lot drainage patterns on sheet I of the Residential General Plan.
❑ Residential Lot Permit.. The following items are required to obtain this permiomp
t: cleted
application, site plan, and fee. PAGE 3 "FINANCIAL RESPONSMILITYIOWNERSHIP FORM°'
not required.
Fee Re uiremennFff_nVirOnMnntaq11
ments:
$100 flat feewing property boundaries. The site plan required by the
Health or Central Permitting Departments is sufficient.
ALL CHECKS MADE PAYAPLE To CHATHAM COUNTY
Pagel of 3

A f. I , 1 , .t
Land -Disturbing
Permit Application
"The mailing and street address of the principal place of business for the Person/entity financially responsible and
the land owners) must be provided. A P.O. box is NOT acceptable as an address.
"*If the financially responsible person/party is different from the current land owner, an agreement signed by both
parties must be provided allowing the financially responsible party person to conduct the land -disturbing activity on
the property.
PROJECT NAME: _lC6, vt ; ;) t1 ��' •t' e ��; DATE:
ADDRESS OF PROJECT:
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: ;. i _< o
PARCEL #(S): � f? c�
TOTAL DISTURBED ACRES or SQUARE FEET:
PURPOSE OF ACTIVITY: lj �
FEE AMOUNT SUBMITTED: 9/ .d(')
*LANDOWNER S OF RECORD attach R49LILo Iist additional owners
Please provide a complete list of partners, managing members and registered agents if the responsible entity or
laud owner is a group of indivCiduals, corporate organization or entity.
Name: ��'tt� f:tt GIS S:,hn.i{iC� i Phone: �,�?_)'-iCi;'(,`J
Address: t 1,? r c ? L z E-Mail: f -e P, t L c' .
UCH 2 Signature • `
r
North Carolina)
Name: Phone:
Address: E-Mail:'
ENGINEER/SURVEYOR
Company Name
Address: _
Contact Person: e o' 1--z n r " r,
Phone: «i,tej . "7 �-j t
in
E-Mail:. /- r'
Signature:
EROSION CONTROL
Person to contact should erosion & sediment
control issues arise during land -disturbing activity:
Contact Person: _iC,
t,�Q ► o j_,J O yIr L
Company Name:
Phone: lei
E-Mail: �r� r' �' z ` ��----
P'�
Page 2 of 3

Soil Erosion and Sedimentation Control
` "„„ ` , Financial Responsibility/ownership Form
NOT REQUIRED TO BE COMPLETED FOR RESIDENTIAL LOT PERMITS.
PLEASE READ THE FOLLOWING INFORMATION:
1) This section must be signed in the presence of a Notary
2) All Land -Disturbing permits are valid for up to (2) years from the date of issuance. If circumstances wan -ant, 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. If the pen -nit is revoked, all other
permits and approvals are 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 an
for violations of the Chatham County Soil Erosion and Sedimentation Control Ordinance. This penalty is up to $5000.00 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.
3) The information provided on this form is true and correct to the best of my knowledge and belief and was provided by me while
under oath.
4) This form must be signed by the property owner if an individual. If owned by a company or corporation, this form must be signed
by an officer, director, partner, attorney -in -fact, or other person with authority to execute instruments for the corporation and
accompanied by a complete list of all partners, managing members and registered agents of the company or corporation.
OWNER OF PROPERTY:
Name and Title: C- P 1 C_— _&" r1.fA L--r) i S"
Company 1
Signature:
ADDITIVINAL VINANCIALLY RESPONSIBLE P
Name and Title: 1
company:
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
eC- V--,
TY (if any):
�- I0--( r^
✓ -ex- � V�C< V-cky U0
I,_ IRO MDAA R MAC CIAnl1 a Notary Pub] icof C.hd4harn
of IJ D Y }{� ('„� p � � A a County in the state
do hereby certify that E LO H O V 1 personally
appeared before me this day and under oath acknowledged reading the information above and acknowledged thatthe
above form was executed by him or her.
Witness my hand and official seal, this the 1 1 day of_ ,Sa n o► rU , 20 2�, ����'""�++",,,�
PR"Ma
�vi. n Ada 2 Mah a i and ,• �?�O�omm. �.4 ;�'.q o's
Notary Public _���+W p��t0 U)
s
NOTARY
My commission expires 11 t2U Zt�• (SEAL) �,� PUBLIC o
/I�AI{01U,