NCC232256_FRO Submitted_20230727

Orange County Planning & Inspections Department
ORANGE COUNTY 131 W. Margaret Lane, Suite 200, Hillsborough, NC 27278
NORTH CAROLINA 919-245-2575 or [e-mail]
Land Disturbance Permit (LDP) Application
Please refer to instructions and checklist in completing the following application.
If completing by hand, please use black or blue ink.
Date: 5/12/2023 Case Number:
Check all that apply: n Erosion Control Plan
n Stormwater Permit
n Stormwater Management Plan
General Submittal Information
Name of Project: 233 Tumbling Brook Lane
Parcel ID Number (PIN): 9866911829 Planning Jurisdiction: Orange County
Size of Tract: 10.07 acres Area Disturbed 2.58 acres
Fees — Section Completed by Staff
Fee Amount
Erosion Control Plan Review
Required with Application $387
Land Disturbing Permit 774
Optional with Initial Application $
Stormwater Management Plan Review
Orange County Planning Jurisdiction Only
Required with Application ft.$300
Total $ 1 ,461
Approximate date land disturbance will begin: 7/10/2023
Contact Information
Landowner(s) of Record (Use additional pages if necessary and attach to application):
Name: Mark & Cindy Frazier Name:
Street Address: 4703 N Thomas Rd Street Address:
Current Mailing Address: Current Mailing Address:
4703 N Thomas Rd
City: Freeland City:
State: MI Zip: 48623 State: Zip:
Phone: [phone] Phone:
Email: [e-mail] Email:
Page 1 of 4

Contract Purchaser (if applicable) (Use additional pages if necessary and attach to application):
Company/Organization: Company/Organization:
Contact Person: Contact Person:
Street Address: Street Address:
Current Mailing Address: Current Mailing Address:
City: City:
State: Zip: State: Zip:
Phone: Phone:
Email: Email:
Person(s) or Firm(s) Financially Responsible for this Land Disturbing Activity:
Company/Organization: Mark & Cindy Frazier Company/Organization:
Contact Person: Mark & Cindy Frazier Contact Person:
Street Address: 4703 N Thomas Rd Street Address:
Current Mailing Address: Current Mailing Address:
4703 N Thomas Rd
City: Freeland City:
State: MI Zip: 48623 State: Zip:
Phone: [phone] Phone:
Email: [e-mail] Email:
Registered Agent (if any) for the Person(s) or Financially Responsible Party:
(NOTE: a North Carolina agent is required if the applicant is not a resident of North Carolina)
Name: Dillon Smith Name:
Street Address: 221 Providence Rd Street Address:
Current Mailing Address: 221 Providence Rd Current Mailing Address:
City: Chapel Hill City:
State: NC Zip: 27514 State: Zip:
Phone: [phone] Phone:
Email: [e-mail] Email:
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Additional Project Information
Project Description (detail the scope of the project and nature of land disturbance):
Two story residential house is proposed on this site. Land disturbance will include construction of this
house, driveway, parking pad, pool, septic area.
Permits completed:
I P22-0207
Permits in progress:
Well Permit W22-0179
Construct. Auth. CA23-0122
Plans Prepared by:
Name of Person/Firm: Ballentine Associates, PA
Contact Person: Dillon Smith, PE
License Number: 042542
Mailing Address: 221 Providence Road
City: Chapel Hill State: NC Zip: 27514
Phone: [phone] Email: [e-mail]
Page 3 of 4

Certification and Signatures
Signature and Witness: The above information is true and correct to the best of my knowledge and
belief and was provided by me while under oath.
Mark & Cindy Frazier
i n r financially Responsible Party Type or Print Name Legibly
Property owner 5 /Z- Z3
Title or Authority Date
1, e 'h.4 c- \,;ve,cS a Notary Public of the County of GA.c, -,,.--
hereby certify that V\..A., 1= t- personally before me this day and
under oath acknowledged that this Application for Erosion Control Plan Approval, Stormwater
Management Plan Approval, and Land Disturbing Permit / Statement of Ownership and Financial
Responsibility was executed by him or her.
Witness my hand and notarial seal, this 124•Day of .0.u _ , 2.0a 3
V-.4-(2---1--C-1 c \ '
Signature of NQtarg,, My Commission Expires
`•• �O R‘D Sy/��.;
SEAL `� NOTARY .
PropertypwffirBAI nctI4dgement
LL :
I herebyv*iowlegq.•t6,tbove information and parties referenced herein have been granted
permissior0 '68 •.f ivelopment activity on referenced property of which I own.
Mark & Cindy Frazier
Signat f Property Owners Type or Print Name Legibly
S `Jz- 2-3
Date
I, e. 4.... 3 \„.,,,W� a Notary Public of the County of C\,,,,. .,,
hereby certify that 11.kq,\,___ ' .,_ - personally before me this day and
under oath acknowledged that this Application for Erosion Control Plan Approval, Stormwater
Management Plan Approval, and Land Disturbing Permit / Statement of Ownership and Financial
Responsibility was executed by him or her.
Witness my hand and notarial seal, this lz.tt- Day of dA-.. , 6 .3
nature of Notary My Commission xpires
� °RIDS
SEAL,' : i.s-'.
NOTARY .
i••. PUBLIC :u. ,
=%,y'.y�•• ..M .�y Page 4 of 4
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