NCC230842_FRO Form_20230328

Applications may be submitted online:
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https:/lchatllamcountync.viewpointelotid.com/categories/ 1082
Land -Disturbing
Permit Application
Please include all re aired signatures. 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. plan, and fee requirements
apply to your project and then check one of the boxes below:
VLand -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 Requirements:
Desirncrn 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 trust 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 webpage. Complete table on sheet I 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 Requirements: 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

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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.
V`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 on pace 3 of this application and must be completed in its entirety.
PROJECT NAME: �� h,rjwl'1C,(DATE:
ADDRESS OF PROJECT: 1U>
LATITUDEILONGITUDE OF PROPERTY AT SITE ENTRANCE:
PARCEL ##(S): L� 'j _.
TOTAL DISTURBED ACRES or SQUARE FEET:
PURPOSE OF ACTIVITY: ��,� 12�s�d►e►.k��l �-lo�•e
FEE ATMOUNT SUBMITTED: RIVER BASIN: CAPE FEAR
"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: ChriSirgahr-r Phone: q lq - 547- 571 b
Address: 5 Q �- reenhi E-Mail:
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Signature:
"TIN RESPONSIBLE PARTY (applicable only if different from rp_opert owner)
Name: - r7 SJmpkeex L Phone:54
Address: ob=�' �rl i 0
, Dg E-Mail: i .r Cpm
C Signature:
il1ORTH CAROLINA AGENT (applicable only if either owner or financially responsible party does not
X reside in Not Carolina)
Name:
Address:
ENGINEER/SURVEYOR
Company Naive:
Address:
Contact Person:
Phone:
E-Mail:
Phone:
E-Mail:
Signature:
EROSION CONTROL
Person to contact should erosion & sediment
control issues arise during land -disturbing activity:
Contact Person: .)01�1111 I
Company Naive:
Phone: .j 34' - E.t_., -
E-Mail:
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Page 2 of 3
ANTICIPATED START DATE: ANTICPATED END DATE:

Soil Erosion and Sedimentation Control
C'IiA"I-IIAIvt CCAIN-I-Y
Financial Responsibility/Ownership Form
NOT REQUIRED TO BE COMPLETED FOR RESIDENTIAL LOT PE"ITS.
PLEASE READ THE FOLLOWING INFORMATION:
1) This section must be signed in the presence of a Notary.
2) This form must be signed by the property owner if an individual. If aivned by a company or corporation, this form must be sighed 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.
3) This form must also be signed by the financially responsible party and NC agent (if applicable). Same provisions of 4 2 above apply.
41 If the landowner and financially responsible party are different, the completion and signing orthis page shall serve as documentation
acknowledging the landowner consents to and authorizes the financially responsible party to undertake the proposed land -disturbing activity on the
landowner's tract(s) of land identified on this application.
5) 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.
6) 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 writ€en 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 Erasion 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.
OWNER OF PROPERTY:
Name and Title: 1 L •
Company (if applicable):
Signature:
FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner):
Name and Title:
Company:
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title:
x Company:
Signature:
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I, D 1i N ? c5r P— „ , a Notary Public of h_1% M County in the state
of f V do hereby certify that ar%,P} obtI. TI �Gpw 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 —day of �J9 6, 20�
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Nota Public s
My commission expires
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