NCC221567_FRO Submitted_20220421

Lattd»Disttirbiug
Pernik Application
Plxasc complete both pages, of this roan and return tct:
Ph) sical AL1dri5,S Flailing Address
!3(E t=ast St. f'O Box S�3t;
f'ittsbc�ru. NL ?7; I Pittshoro, N-U 27.31
Phone [phone]
Please see PERMITTING FL.L) V CIIARJ to cfetirnline which perrnit and plan rt t�iairrmrntN uppt4 t%)-
3 our prr3jcct and then check one of the loxes h, fow:
>tnr!»l)Ivturhin8 Permit. -rhe following items are required to obtain this percent: com leted
*'application, plans, deed. and lees. land -Disturbing pemlit applications mull includalp
I�at.s on one application with the tOt:tl amount of disturbance for all parerVIots. ,,"n clearing e all l �d
els.
disturhanec must be Included -A hen calculatin disturbed area.
Fcc Riquirenacntt: ---- ___
Pcrmit Fee: IrheLl acre
Plan Rc,iew FCC. S250/diswrbed acre----
} ces are rounded up to the next a4hi�lc acre.—
f=xart�ple-i acre or Irsx is Sr5t)fl, I.01.2 acre (100, and 2.01-3 is SI.5()O.
Plan Requii-rmcnis:
h! ►1, f lone submit (I ) rupy� v� f an erosion tuntrul plan rci:n},jetc,l
.S 4rafzd h�T:i prcitr� ssicrnxl [+€rcj
sort c)or, protl6sional enl,;inecr, or registered Uidscapc archacct rjj, l,ia>1 trust nacit the criteria oi'tt,c
Chathain Count-,- Erosion Control Plan Kcvie%s- Checkli.,t and include all applicable constructioll details.
Thee can be found on the Chatham County Watershed PrI>trcti:tin web itc, kan the FR)sion Control
wcb aI~e. '!his Ian must sadsfs, t111 Iaettl. state, and tedersl minirtaum Ian rc* uiretalcrats.
en t:l P s n submit (I j copy ofsite plan along with the Chatham ('aunt} Kesidential General Plan.
plan is not required to be completed by a design profession.tl. '',he the CWatershed
5 itr
Residential General Plan c:ala be f.�un.i
tut of drains ltathant Count} 1 'atcrshed F'rofixtion website ran the Residential Construction -Ncbpagc- Indicate
c aUern s} orb sheet l af'thc Residential General flan.
11
Residential t.nt Permit. Tlae following items arc required to obtain this permit: completed
application, site plan. and fee. PAGE: 3 "FINANCIAL RESPONSrall-ITY/OWNERSIIIP FORM —
not not re uircd.
Fee Rc uirements: I Ian lac uirements:
S 100 flat fee Site Plan showing; property boundaries, The site plan required by the
Environmental Flcattla or Central Permit De anments is sufficient.
At.L CHECKS 41ADE PAYABLE TO CHA t1i,•1;Rt COUNTY
Page 1 of 3

'E'l IAI'll /Aria C."t2t 1M'1Land-Disturbing
Permit Application
"The ntsiling and street address of the Principal place of business for the person/entity financially responsible anti
the Nod awner(s) must be provided. A P.O. box is NOT acceptable as an address.
•"If the rinaneeally responsible person/party is different from the current kind mi ner, an agreement signed by both
parties must he provided ailo»ing the financially responsible Party person to conduct the land -disturbing uctivity on
the prol►erty,
PROJECT NAME: r' h 2 2 2 1
...._._ � j,1.. L.Q� DATE: � f �° ``�� t
A©t�[tEss t E PROJECT, ,. N r't f5' ]` r4L 70-7-,fgok-) h� 2 73 J Z.
LATIT[?DMONGITUDE OF PROPERTY AT SITE ENTRANCE:. <?O/ 053 r04�yt+'
PARCEL N(S): � C?� —7/
TOTAL DISTURBED ACRES o, s 1JARE FFE:T: _ 1 . -75 a cYCS
PURPOSE OF ACTIVITY:- G rU :ti. f ~ A � C�^r-r'.A
FEE AMOUNT SVOMITI'E(];
«"i:A i7nWTAERfS) UI RECORD (attach P,grge to lisl additional owners)
Please provide a complete list or part managing members and registercd agent, if the responsible entiIN of
land oK ncr is a group of individuals, corporate: arganuation or entity.
Name: G Phone: l (1 _ 6 0
----
Address: 201 12j) i Mail: i
n p q • 00"
*! Net A Y RESPONSIBLE PARTY lappli •sib! tgnl� if Milli rent from nro rt,. m%mien
Name: Pholic.
Address: � �( F-Alai€.
Signature
NORTH CAROLINA AGENT fannlicable oniv ifo%%ner or finarteiall4 rr5tu,n,ihlc �a�t� dc,es nc? rep€cic
North Carolina)
Address:
NGINE'R1
Company Name: CC f'L-V ►. 3U T V f
Address:
Contact Person:
Phortc: _ lq 9 G 9' 4 73 F
E-Mail. 37U1.114uh
I:-I4lail: -_.---
Signature.
ER0SIQN C.0 N-TR0L
Person to contact should erosion & sedirttent
control issues arise during land-distu rbing activity;
Contact Person:
Company Name
Phone:
E-Mail:
Page 2 of 3

.��. Soil Erosion ansl ti�•(iinli%ut.11ian C.'ullllt)I
C.,�1IA'1'1I ltit C`()IIIY'1'1'
•� ~ r� • r"' r F1ll:Incltli Rl'til)(insil)ili(YIO►%Ilerxliii) Form
<17V REQ1 fiRcn '1't) BE C0,111 r1. ETED Fol? h't:.S'IUF::1r71: f 1, Lf 17' 1'F. RAIll 4
I'Lr;r1Sf I(r:A11 111: 101- It %VlNti INi-QIi 4t?l r^i0N:
1) This section trust be signed in the prescnre.:Fa htutaq
D rill Land -disturbing pemtits art valid lOr tip to (21 )-cars 6,3111 tltc dale ul' i;su;tnce it circ[tnts[ances warrant, the pemlit ntri be
ertendcd for (2) years per titc cundilianz of the Chathattt County Snit t'tosirnt nerd Scdinwntalion ('artlrul Ordittancc. Upon %%rttlot
notice. the Land perntil may be revoked tier rsihtre to crtatpl) ►%i[h the Ordinance If the permit is revoked, all other
perrtsiis and approvals arc withheld until the pn+perty is Once again in compliance with ('hatluttrt Goon[% rcgillatiuns. :Also. ulxrrt
►►ritten. notice, a civil penalty (fine) earl be instigated against the properly owlter and:'or addi[ionrl firtancialty rrspctnsiblr party of any)
for violations of the Chatham County Soil Erosion and Sedimentation Control Orditrancr •thin p►-ttnit) is up to S5000 00 pt:r tit%I:ttion per day and is assessed daily for evcry day the prapcny° is in violaurut Intcrfcryn pith or Irampctitt an ittslrr% tion c:ur restrJ[ in a t n tl
Penalty without written notice.
31 The information pnn ided on this farm is true and vorrect tit the best of my kauw, k-dge and belief and Has provided by me %%'hilt
under onih
41 This form must be signed by the properly owner if an individual. I f awned by a company or corporati.xt, this Forst must be signed
by an nflicer, direclot. partner, nuorne) •in -fact, or other person +with authprity to exeetr[r instriancois for the corporation and
accompanied by a cumptat list of all partrrers, mana..ittg ntetatbrrs arsd registered agents of the campany or co"ratiurt.
OWNER OF PROP[FRTY:
Name and Title.: t W
Company (if applicable):
Signature:
ADDITIONAL FINANCIALLY RI'.SPONSIBI.E PAR T1' (if snv):
Name and Title:
Company:
Signature:
NORTH CAROLIiNA ACENT (if any):
Name and 1'iIle:
Company:
Signalure:
a Notary Public of O)o kQ
_Cctunrt in the stale
of 1 do hereby certify that..__J~.s,,�
prr�s.�nally
appeared before me this day and under oath acknowledged reading the information above and akknc%.vled ed that the
above form was executed by him or her,
Witness my hand and official seal, this the � � day olj_ cg
— = J�p,l. PAre''//,
C �
_ Notery public
My'commissionexpires to yap _ Nratca
t�f�'Ity
My comm. EXP. :
'%. 02.05.2023 �V,;
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