NCC230960_FRO Submitted_20230405

Land-Disturbing
CIN IATI I1A tM oC > 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 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 page 3 of this application and must be completed in its entirety.
PROJECT NAME:G 6 very'e'3 C:11,10 ii+A?e; DATE: 3 -2 3-2.3
ADDRESS OF PROJECT: .2,2e pc yvrp.<-e c A��4/ A/S7/ N C- .2 75%7
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 3 S°5-0 I-29,8.t N 71'03'Nd.L" W
PARCEL#(S): 0 0 7 O 9 6
TOTAL DISTURBED ACRES or SQUARE FEET: Ja,00 o
PURPOSE OF ACTIVITY: IU La, S;jln .1 Q � 57(i�U[ Ito
FEE AMOUNT 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: 641-e i L R e, n; Phone: 775--.7t)
Address:,2 JQ/Nos P
Carl A L L. E-Mail: 5/'vhl .'
/ , t- ?7 S 1 9 Signature: i
/4"
**FINANCIALLY RESPONSIBLE PARTY(applicable only f different o
propertyOwner)
Name: SAecoys- Phone:
Address: E-Mail:
• Signature:
NORTH CAROLINA AGENT(applicable only if either owner or financially responsible party does not
reside in North Carolina)
Name: 5��, Phone:
Address: E-Mail:
Signature:
ENGINEER/SURVEYOR EROSION CONTROL
' Company Name: G;v;/ lam„s.//and-5 Person to contact should erosion&sediment
Address: 37031 L yG/Cast ekwy S,.../- 20/ control issues arise during lan -disturbing activity:
—��✓ , Nr � 77o j Contact Person: R- r p•u pc,.
Contact Person: /�,1�cv SOH�S e,a. Company Name: es Q 9(rr
Phone:_0_49_ yyo_jh 5 Phone: 9'/9_36c - /747
E-Mail: GT ri,., , 1 n e j `o
Page 2 of 3
ANTICIPATED START DATE: 3_Z 3- 2-3 ANTICPATED END DATE: I e -3 /- 2 3

CHATHA IJNTV
Soil Erosion and Sedimentation Control
NItl p 1 11 , N I,1 1 4 1
-� Financial Responsibility/Ownership Form
NOT REQUIRED TO BE COMPLETED FOR RESIDENTIAL LOT PERMITS.'
PLEASE READ THE FOLLOWING INFO
I)This section must be signed in the presence of a Notary. RMATION:
2)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
partners,managing members and registered agents of the company or corporation.
3)This form must also be signed by the financiallyresponsible a
4)If the landowner and financially responsible p party and NC agent(if applicable).Same provisions of#2 above apply.
acknowledging the landownerponsible party are different,the completion and signing of this page shall serve as documentation
landowner's tract(s)of landidentified ton this application.
d the financially responsible party to undertake the proposed land-disturbing activity on the
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)MI Land-Disturbing permits are valid for up to(2)years from the date of issuance.If circumstances warrant,the permit may be extended f.
e.
(2)years per the conditions of the Chatham County d
permit may be revoked for failure to comply wit thetOrdl ianceattIfthe Sedimentationmit s revoked,0all other permits and approvals are Land-Disturbinginance.Upon written notice,the ithheld until
the property is once again in compliance with Chatham
against the property County regulations.Also,upon written notice,a civil penalty(fine)can be instigated
p pe 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.
p
OWNER OF PROPERTY:
Name and Title: Sp hx, l
Company(if a .licable): DU han1
Signature: 4 /� �'�
AIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIt
FINANCIALLY RESP0 'SIBLE PARTY(applicable only if different from property owner):
Name and Title: a-r,7-e
Company: -
Signature:
NORTH CAROLINA AGENT(if any):
Name and Title:
Company:
Signature:
******************************************************************
!ill
l' P1NA- Cald liti-Q L( ,a Notary Public of
of (?y��j 41�1 do hereby certify that County in the state
rsonally
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. �J2
Will ess my hand and official seal,this the G J��
G Oited,/.0-e-gt
day of � Z�i ri��� ,,,,,,,,,,,III,,,,,,,,,
Notary Public .�``��G� .0 on�ly�.,,
pp�� ���16�i
My commission expires U�•l�.2 "C., `r 1 '•<<'
_'�9T djOUBL�o1 •�
h 6,
Page 3 of 3 /y "'•
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