NCC222817_FRO Submitted_20220808

C I I A-FI I A A4
?1 [ Y it l is C: h it t'7 k. I R it
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:
0 Land -Disturbing Permit. The following items are required 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 in acres for all parcel/lots. All clearing and
disturbance must be included when calculating; disturbed area.
Fee Requirements:
Permit Fee: $250/disturbed acre
Plan Review Fee: $250/disturbed acre
Fees are rounded up to the next whole acre.
Example: 1 acre or less is $500, 1.01-2 acres is $1,000, and 2.01-3 is $1,500.
Plan
Design Plan: submit (1) 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
webpage. This plan must satisfy all local, state, and federal minimum plan requirements.
General Plan: subunit (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 pattern(s) on sheet 1 of the Residential General Plan.
❑ Residential Lot Permit. The following items are required to obtain this permit: completed
application (if required, see note 4 on PERMITTING FLOW CHART), site plan, and fee.
Fee Requirements:
Plan Requirements:
$100 flat fee
Site Plan showing property boundaries. The site plan required by the
Environmental Health or Central Permitting Departments is sufficient.
ALL CHECKS MADE PAYABLE TO CHATHAM COUNTY
Page 1 of 3

CA IATI IA L'"Cli _Fy
tJ ll Ii F FI £ h R fs L INA
Land -Disturbing
Permit Application
**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. 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:
Chatham Park Ph4A-Lots ioi-111,140-145,529-543,582-585 DATE: 06-10-2022
ADDRESS OF PROJECT: Chatham Park - Near Vine Parkway
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.7246,-79.1587
PARCEL #(S)• refer to sheet 4 of this document
TOTAL DISTURBED ACRES or SQUARE FEET: 3.30 ac
PURPOSE OF ACTIVITY: To grade out lots in preparation for building structures.
FEE AMOUNT SUBMITTED: $2,000.00
**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 of individuals, corporate organization or entity.
Name: Tri Pointe Homes, c/o Bob Davenport Phone: [phone]
Address: 1330 Sunday Dr, Suite 101 E-Mail: [e-mail]
Raleigh, NC 27607 Signature:
**FINANCIALLY RESPONSIBLE PARTY (applicable only if different from roe owner
Name: Phone:
Address: E-Mail:
Signature:
NORTH CAROLINA AGENT (applicable only if owner or financially responsible party does not reside in
North Carolina
Name: Phone:
Address: E-Mail:
ENGINEER/SURVEYOR
Company Name: The Nau Company
Address: PO Box 810
Rolesvilie, NC 27571
Contact Person: Agnieszka Nau, PE
Phone: [phone]
E-Mail: [e-mail]
Signature:
EROSION CONTROL
Person to contact should erosion & sediment
control issues arise during land -disturbing activity:
Contact Person: Kristi Dillard
Company Name: Tri Pointe Homes
Phone: [phone]
E-Mail: [e-mail]
Page 2 of 3

Soil Erosion and Sedimentation Control
µ w� Financial Responsibility/Ownership Form
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 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. If the permit 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 any)
for violations of the Chatham County Soil Erosion and Sedimentation Control Ordinance. This penalty is up to $5000.00 per violation
per day and is assessed daily for every day the property is in violation. Interfering with or hampering an inspection can result in a civil
penalty without written notice.
3) The information provided on this form is true and correct to the best of my knowledge and belief and was provided by me while
under oath.
4) This form must be signed by the property owner if an individual. If owned by a company or corporation, this form must be signed
by an officer, director, partner, attorney -in -fact, or other person with authority to execute instruments for the corporation and
accompanied by a complete list of all partners, managing members and registered agents of the company or corporation.
OWNER OF PROPERTY:
Name and Title: 'e00
Company
Signature:
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY (if any):
Name and Title:
Company:
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
a Notary Public oCounty in the state
of COL-Yd t 1► r'.. do hereby certify that -$ ob 1� �7cr� k 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 i0 day of �2022
Notary Public
My commission expires ©C 1ae �� 21v 0 T q R {SEAa
pU B LtG
i LL,9 CMG:
/ COUN�y
Page 3 of 3

Lot Number
Parcel Number
101
95143
102
95144
103
95145
104
95146
105
95147
106
95148
107
95149
108
95150
109
95151
110
95152
111
95153
140
95182
141
95183
142
95184
143
95185
144
95186
145
95187
529
95405
530
95406
531
95407
532
95408
533
95409
534
95410
535
95411
536
95412
537
95413
538
95414
539
95415
540
95416
541
95417
542
95418
543
95419
582
95420
583
95421
584
95422
585
95423