NCC231308_FRO Submitted_20230509

Land-Disturbing
C'' i i 1AM C'C)C lNT1' Permit Application
v .) K�a 1 61 a n n n.. . in
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:
E✓ Land-Disturbing Permit. The following items are required to obtain this permit: completed
application, plans, deed, and fees. Land-Disturbing Permit applications must include all parcels/
lots on one application with the total amount of disturbance 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 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 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: 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.
E✓ 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. 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

Land-Disturbing
C'VAT!I A i . PILR'ITY 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: Everbrook Subdivision DATE: May 13, 2022
ADDRESS OF PROJECT: 35-190 Big Bear Drive(off of Pea Ridge Road)
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35043'43"N,79004'44"
PARCEL#(S): 65701, 94685, 94686 and 94687
TOTAL DISTURBED ACRES or SQUARE FEET: 38,400 S.F.
PURPOSE OF ACTIVITY: Construction of a Roadway
FEE AMOUNT SUBMITTED: $500 (prey. submitted)
**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: Anthony Prusik and Margaret Prusik Phone: [phone]
Address: 190 Big Bear Drive E-Mail: tonya yah .com
Pittsboro, NC 27312 Signature:
**FINANCIALLY RESPONSIBLE PARTY(applicable only if different fr m property 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:
Signature:
ENGINEER/SURVEYOR EROSION CONTROL
Company Name: RWK,PA Person to contact should erosion &sediment
Address: 101 West Main Street control issues arise during land-disturbing activity:
Suite 202 Contact Person: Sean M. McLean
Contact Person: Sean M. McLean, P.E. Company Name: RWK, PA
Phone:[phone] Phone: [phone]
E-Mail: [e-mail] E-Mail: [e-mail]
Page 2 of 3

.. ‹ Soil Erosion and Sedimentation Control
CHATHAM C(7UN Financial Responsibility/Ownership Form
: A NI (i R I H C A IC t} 1 I NA
NOT REQUIRED TO BE COMPLETED FOR RESIDENTIAL LOT PERMITS.
PLEASE READ THE FOLLOWING INFORMATION:
I)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: Anthony Prusik and Margaret Prusik,Owner
Company(if ap r b e - /a e
Signature: 1/
ADDITIONAL FINAN ALLY RESPONSIBLE PARTY (if any):
Name and Title:
Company:
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
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I, moure CAI., a w€w ,a Notary Public of l ika VVL. County in the state
of No i-i Ca-KA 6 O do hereby certify that P-ryt1'Iov, i'V 9 J L(Sy, personally
appeared before me this day and under oath acknowledged reading the infonnadion above and acknowledged that the
above form was executed by him or her.
Wi ess my hand and official seal,this the �i` day of Mtn ,20 2-3
f2c`�G\F:�sion��.!!
Notary Public yr.'-f� ''..
My commission expires M v c.N(p, L 1 z \ 4L) U''
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Cy.% .March6:12. �,��
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