NCC222832_FRO Submitted_20220809

�HATi i-j CC7�tiNTY
.r ! 1, le If�l
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:
El 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 parceI/lots. All clearing and
disturbance must be included when calculating disturbed area.
Fee Requirements:
Permit Fee: $2501disturbed 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 Requirements:
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 rneet 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 age. This.plan must satis all local, state, and federal minimum lan re uirements.
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 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 Permittinjz Departments is sufficient.
ALL CHECKS MADE PAYABLE TO CHATHAM COUNTY
Page 1 of 3

Cl-iAxtllAm C:nUN7`Y
N" H l H C A It it ! I Ni A
Land -Disturbing
Permit Application
**The mailing and street address of the principal place of business for the person/entity financially responsible and
the rand owner(s) must be provided. A P.O. box is NOT acceptable as an address.
**if the f nancially responsible person/party is different from the current land owner, an agreement signed by both
parties must be provided allowing the f nandally responsible party person to conduct the land -disturbing activitY on
the property.
PROJECT NAME.• 504 Henleys Mill Road
DATE: 06-20-2022
ADDRESS OF PROJECT: 504 Henleys Mill Road, Pittsboro, NC 27312
LATITUDEILONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.6555,-79.2278
PARCEL #(S): AKPAR:76929
TOTAL DISTURBED ACRES., SQUARE FEET:
PURPOSE OF ACTIVITY: Building new home
FEE AMOUNT SUBMITTED: $1.000.00
1.15 ac
**LANDOWNER 5 OF RECORD] attach 0ge 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: Craig and Sheila Clair Phone: [phone]
Address: 765 Moms Road E-Mail: homefixations@yahoo_com
Pittsborough, NC 27312 _ Signature: _ _q- E
**FINANCIALLY RESPONSIBLE PARTY (applicable only if different from propertyowner)
Name:
Address
Phone:
E-Mail:
Signature:
NORTH CAROLINA AGENT (applicable only if owner or financially responsible pany does not reside in
North Carolina)
Name: Phone:
Address:
ENGINEER/SURVEYOR
Company Name: The Nau Company
Address: PO Box 814
Rolesviile, NC 27571
Contact Person: Agnieszka Nau, PE
Phone: 91 "24-4875
E-Mail: ansu@thenauco_com
E-Mail:
Signature:
EROSION CONTROL
Person to contact should erasion & sediment
control issues arise during land -disturbing activity:
Contact Pcrson: Craig Clair
Company Name:
Phone: [phone]
E-Mail. homefiixa*[e-mail]
Page 2 of 3

Soil Erosion and Sedimentation Control
C"AWM AM Cnunt-rY
""' "' " ` " �" ' 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 Gom 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 andlor 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 sighed 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: Craig Clair and Sheila Clair 1 Owners
Company (if applicable): _
Signature:
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY (if any):
Name and Title:
Company
Signature
NORTH CAROLINA AGENT (if any):
Naine and Title:
Company:
Signature:
a Notary Public of C o County in the state
of. c ll,a�, do hereby certify that r c . �.{ �; r- £�c4i r- —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. rr��� l_
Witness my hand and official seal, this the o day of V uN-R-- , 20aD-
Notary Public
My commission expires 1 Z '� p
NvtatiY Public State of Mich-lgao
(SEAL) County al Macomb 2024
fission Exgires: Decembe' ,
My G0m in the county
vt
p r,W13
Page 3 of 3