NCC231865_FRO Submitted_20230620

DocuSign Envelope ID:72231A3A-1AE7-401C-B418-FB40E7471608 Applications may be submitted online:
J l https://chathamcountync.viewpointcloud.com/categories/1082
Land-Disturbing
CIIATIIAM CC)CIN"I 1
(lit ,� t o tt t- t N Permit Application
Please include all required 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:
0 Land-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:
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 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 1 of Residential General Plan.
El 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 Depatliiient can be used as a base.
ALL CHECKS MADE PAYABLE TO CHATHAM COUNTY
Page 1 of 3

DocuSign Envelope ID:72231A3A-1AE7-401C-B418-FB40E7471608
Land-Disturbing
CI-IA IIA1 4 CcIU Y NT
N �� It U A it Cs /_ INA 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: Chapel Ridge- Lot 215-G DATE: 4-19-23
ADDRESS OF PROJECT: 66 Sweet Meadow Lane, Pittsboro, NC
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.791050/-79.220790
PARCEL#(S): Lot 215- PIN 81745
TOTAL DISTURBED ACRES or SQUARE FEET: 0.45
PURPOSE OF ACTIVITY: Construction of a single family home
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: Richard Huxford Phone: [phone]
Address: 120 Juliet Circle, Cary, NC E-Mail: ric J<�ryPft �Stilbinternet.com
Signature: [� _
`—b02AFACb9bD9421_.
**FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner)
Name: Phone:
Address: E-Mail:
Signature:
NORTH CAROLINA AGENT (applicable only if either owner or financially responsible party does not
reside in North Carolina)
Name: Phone:
Address: E-Mail:
Signature:
ENGINEER/SURVEYOR EROSION CONTROL
Company Name: Residential Land Services Person to contact should erosion &sediment
Address: 1917 Evans Road, Cary NC control issues arise during land-disturbing activity:
Contact Person: Chris Miranda
Contact Person: Dean Rhodes Company Name: Caruso Homes On Your Lot
Phone:[phone] Phone: [phone]
E-Mail: [e-mail] E-Mail: [e-mail]
Page 2 of 3
ANTICIPATED START DATE: 6-1-23 ANTICPATED END DATE: 12-31-23

`4_, Soil Erosion and Sedimentation Control
L I I.\t t i \.xl C r sits. I N
�• , •• , • , , Financial Responsibility/Ownership Form
NOT REQUIRED TO BE COMPLETED FOR RESIDENT/AL LOT PERMITS.
PLEASE READ THE FOLLOWING INFORMATION:
I)This section must be signed in the presence of a Notary.
'_)This form must be signed by the property owner if an indn ideal.If ws licit by a company or corporation,this fame must be signed by an officer.
director,partner.attorney-in-fact.or other person ssnh 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[ono must also be signed by the financially responsible party and NC agent of applicable) Same pros isions of tit 2 abosa apply.
4)If the landossncr and financially responsible party arc different.the completion and signing of this page shall sera a as documentation
acknowledging the landossncr consents to and authorizes the financially responsible party to undertake the proposed land-disturbing activity'on the
landowners tr.ictts)of land identified on this application
5) I he mtonnaunn pros',Jed on this form is tore and correct to the best of my knnssledge and belief and was provided by me shrike under oath.
to All Land-Disturbing permits arc salid for up to I22i years from the date of issuance It circumstances ssarmnt. the penml may be extended for
t 2)years per the conditions of the Chatham County Soil Erosion and Sedimentation Control Ordinance. Upon written notice, the Land-Disturbing
permit may be resoled for failure to comply ssnh the Ordinance If the permit is revoked. all other permits and approsals are ssithheld until
the property is once again in compliance with (hatharn County regulations Also,upon ssntten notice,a cictl penalty(fine)can be instigated
against the property miner and or additional financially responsible piny(if any i fors lolaiions of the Chatham County Soil Erosion and
Sedimentation Control Ordinance.This penalty is up to S5000 00 per s tolation per day and is assessed daily for esery day the property is in violation
intcrfenng with or hampering an inspection can result in a civil penalty ssuhout mitten notice.
OWNER OF PROPERTI': ,
Name and Title: Richard Huxford - Ot 1 re.( I7' f)Y -,ally I /i�/,. ,le [1r4"r —
Company(if applicable):
Signature:_ 1 — -
FINANCIALLY RESPONSIBLE PARTY(applicable only if different from property owner):
Name and Title: n/a
Company:_ _ — -- - -
Signature: - -
NORTH CAROLINA AGENT(if any):
Name and Title: ria - - -
Company:
Signature: _
* * *************************************/*,*/***********************
)\..,
1, ��.`' \..—\-.\ J_ '\LC7� ,a Notary Public of �,�I-1 t'�L County in the state
of do hereby centtj that_Hc_H ..V) .,7.rt.cis) personally
appeared before me this day and under oath acknow lodged reading the information above and acknowledged that the
aboN c form was executed by him or her.
\\ttncss my hand and official seal,this the I C day of I '• l _._'0- ��r�rttttrrr1
a.T
V' aSAgy ,1
Notary Pu 'c Z� _ :
My commission expires GF ISF.AL) = Bus,uC) ?U r.
y -21.'i..;...1.:•:
1
r