NCC230666_FRO Submitted_20230313

Please include all required signatures.
Physical Address
80 East St.
Pittsboro, NC 27312
Phone: [phone]
Applications may be submitted online:
https://chathamcountync.viewpointcloud.com/categories/1082
Land -Disturbing
Permit Application
Mailing Address
PO Box 548
Pittsboro, NC 27312
For Office Use:
Please see PERMITTING FLOW CHART to determine which permit, plan, and fee requirements
apply to your project and then check one of the boxes below:
[and -Disturbing Permit. The following items are required to obtain this permit: completed
application, plans, deed, and fees. All clearing and disturbance must be included when calculating
disturbed area.
Fee Requirements:
See attached PERMITTING FLOW CHART
For fees that 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
web a e. This plan must satisfy all local, state, and federal minimum plan requirements.
General Plan: submit (1) copy of site plan showing proposed disturbance limits 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,
Residential Land -Disturbing Permit web a e. Complete table on sheet 1 of Residential General Plan.
❑ Residential Lot Permit. The following items are required to obtain this permit: completed
application, site plan, and fee. Page 3 "Financial Responsibility/Ownership Form" not required.
Fee Re uirements: Plan Requirements:
$100 flat fee Site Plan showing property boundaries and proposed disturbance limits. The site
plan required by the Environmental Health Department can be used as a base.
ALL CHECKS MADE PAYABLE TO CHATHAM COUNTY
Page 1 of 3

I A I'l I A81 1"t)l J�VJ'V� La ud- Dist u rbing
Peralit 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 party is different from the current land owner, an agreement signed by both parties
must be provided allowing the financially responsible party to conduct the land -disturbing activity on the property.
This agreement is provided tin page 3 Of this application and must be completed in its entirely.
PROJECTNAM E: DATE:
ADDRESS OF PROJECT:
. . ........ ... ..... ..
LATITUDEILONGITUDE OF PROPERTY ATSITE ENTRANCE- ,3S. '14 1420 -1 lla*� sco 6- 0
PARCEL 4(S):, ga5SI
--'6ii
TOTAL DIST1411ir, F)A ES .,SQUARE FEET;
PURPOSE OFAcTivay;
FFE AMOUNT SUBMITTED:
011
BASIN, ('API,-- FEAR
**I-ANI)(.)WN - R S �R,E(70R attach to lied additional owners)
E
Please provide a Complete list ol'partners, managing members and registered agents if the responsible entity or
land owner is a group of individuals, corporate organization or entity.
Name:
. . ..... Plione:
N A CD
bj A
Address: IL
jr
Signature: A - V-zv
Name:
Address:
Mane:
E-Mail;
Signature:
NORTH CAROLINA AGE,
�Jlctft!e �v _owLiej ­--orfnancia� arty notresjde in NorthCarof-na) EST— do
Name:
Address-
ENKjLNF LFRL'!jjjR)LEYQjK
Company Name:
Address:
Contact Persom-56
E-Mail-
Phone:
E-Mail:
Signature.,
EROSION CONTROL
Person to contact should erosion & sediment
control issues arise during land -disturbing activity-
C
Contact person: "
Company Nwne:
Phone:
Page 2 of 3
ANTICRATLED 1-,'.ND DATE:
ANTICIPATED START DATE:

a:arsyA4Ci(j"rrj-V S.oil Erosion anti Sedimentation Control
It VARtil INA
Financial kvsponsibilitY/Ownership Form
NO TR EQ IRED TO Bl,' Cj�,,vtj-,,jE 7ED I*OR R ESIDENTIA L L 0 7TE)?Mj TS.
tL—U-',�READ--SE -F�HE FC—)LLAQ�WINGIN C7i
1) Thi6, sectiori must be signed in the presence of Nlolarv,
2) This tiara" must be signed by tile property Owner if all Individual. lfo-,vntd by a company or corporatio 11, this forin must lie %i&med by all officer,
director, Partner, attorney -in -fact, or other person with authority to execute instrulnents tbr the corPuration and accompanied by a complete list of all
partners, managing members and registered agents of the company or Corporation.
3) lurn'l "lust also be signed by the financially responsible party and W agent i ifopplicable). Same provisions ol'# 2 above apply,
4) If the landowner and financially responsible P-MY Kira, difficrenL the: completion and signing � ofthis
acknowledging the landowner c page hall serve Is doc umentation
consents to authuri2es the tMa0ciallY responsible party to undertake the proposed land-4is u i iv y the
Ituld0wricy'S tract(s) of land identified oil this application. I rb ng act it on
5) 'file irillorritation provided on this lbrin is true and correct to the best of my knowledge and b6cfand was plo� i(led bVint while under oath,
6) All Land-f)ijillrbing pel-a Inils ar
e re valid for up to (2) yi<ars from the date of issuallce, il)e'llermil may be exicilded fbi-
(2) N cals per the conditions of the chalham Comity Soil f:r0si()n anti Sedilljcn
permit may he revoked for fbilurc to CI)Mply'will, the ()' tation Control Ordinance. Upon Ivritten notice, the Land -Disturbing
tile PTOPOrtY is once again in compliance wijj rdirlancc- If the Permit is revoked. all other permits and approvals, are withheld until
I CiloullaIll (70tintY regulations, Also.
against the Property owner and/or additional financially responsible p UPc'n written notice, 3 civil Pellall[Y (line) can lie instigated
Sedimenta6on Control Ordinance. *jb arty ("' any) for V'ollaii(i'lil' s ()f the f- 'hathattl (*oUrI1]V Soil Erosion mid
Interfering with or hall is Penall.N. is 111) (1) S500Q00 Per violation per day and is assessed
hampering an inspection result in a civil Penalty u.ilhout Written pollice� daily for every day the propert�, is in violation.
OWNER OF PROPERTY:
Name and Title,.,_Ct0-re--
HNANGIAL11,Y RESPONSIBLE PARTY (applical)1e only if different from property owner):
Name wid Title:
Company:
Signature:
NORTH CAROLINA AGENT (if any):
Narne and'Fitle;
Company:
Signature:
a Notary Public of
County in the state
do hereby certify tha County
.
personally
ore me this clay and under oath acknowledged reading the infonna'tion above a
appeared bef
above form was executed by hint or her,
and acknowle ged thatthe
Witness my hand and official sea]. this the—LC)!�' av of
Notary Public Public
MY commission e)pims—
(SEAL)
E REGINALD M WRIGHT
Notary Public - North Carolina
n
Page 3 of 3 Wake County
),Pl,
My Commission ExPltft Jun 28, 2025