NCC240315_FRO Submitted_20240209

Applications may be submitted online:
https://chathamcountync.viewpointcloud.com/categories/1082
Land-Disturbing
CHATTIANI CC)LINTY
N RIF C A It CD l- INA 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:
❑ 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.
❑ 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

Land-Disturbing
I I,tit 1. t I )t ate ti 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 entiret.
PROJECT NAME: 890 Collins Mountain Road DATE: 6/12;2023
ADDRESS OF PROJECT: 890 Collins Mountain Rd,Chapel Hill, NC 27516
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.862689/-79.224505
PARCEL#(S): 95786:95966;95967:95968:95969;95970;95971;95972;95973; 1212
TOTAL DISTURBED ACRES or SQUARE FEET: 4.57 AC
PURPOSE OF ACTIVITY: New gravel road
FEE AMOUNT SUBMITTED: $2,500 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: HONG TIEU NGO Phone: [phone]
Address: 6515 BURNING TREE DR E-Mail: [e-mail]
HOUSTON.TX 77036 1
Signature: = _ )
**FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner)
Name: Carolina United Grading.LLC Phone: [phone]
2732— Saxapahaw Bethlehem Church Rd. a adams [e-mail]
Address: E-VIaiL•
Graham,NC 27253 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: Ballentine Associates.PA Person to contact should erosion &sediment
Address: 221 Providence Rd. control issues arise during land-disturbing activity:
Chapel Hill,NC 27514 HONG TIEU NGO
Contact Person:
Contact Person: _Lee Price _ Company Name: N1A _
Phone:[phone] Phone: [phone]
E Mail [e-mail] E-Mail: [e-mail]
Page 2 of 3

trj-
- Soil Erosion and Sedimentation Control
C'Ff,vt I[A14t C.OlMIN I'Y
• Financial Responsibility/Ownership Form
NOT REQUIRED TO BE COMPLETED FOR RESIDENTL4L LOT PERMITS,
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 owned by a company or corporation,this form must be signed by an officer.
director,partner.attorney-rn-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 2 above apply
4)if the landowner and financially responsible party are different,the completion and signing of this 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 written notice, the Land-Disturbing
permit may he 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 he 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$ 000.00 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 eivri penalty without written notice
OWNER OF PROPERTY:
Name and Title: SONG TiEU NGO
Company(if applicable): NIA
Signature: ��\4. l�}.
FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner):
Name and Title: AUSTIN ADAMS.OWNER
Company: CAROLINA UNITED GRADING.LLC
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title:
Company: - - — - - - -
Signature:
********* c=ic*************************F***qc****CI*I******************
I, Atri ' Ki�kf' . a Notary Public of_ANyvieetce CO fri County in the state
of /J0-11 ',l do hereby certify that Hall N by 1[Aron w.a. G!edi l�iersonally
appeared before me this day a 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 rt1 ) . 2Q 21i
Notary Public <Ci�. `Cyr:
My commission expires /0/14 f 20Z. - f•-•: 0-\" (SEA.)
�~ ��\V ;2Q`
pv
Page3of3 i� '„AMAN '•
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i��NOR 1 -0,

Land-Disturbing
CI IATI IAft C uavry( 11 r1 I NI A Permit Application
M ►1 M I It A ►
**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 Ian ,i' sp:r,an agreement signed by both parties
must be provided allowing the financially responsible party to conduct Mize end-disturbing activity on the property.
This agreement is provided on page 3 of this application and must be e;mjpikted in its entirety.
PROJECT NAME: 890 Cotins Mountain Road DATE: 6112Q023
ADDRESS OF PROJECT: 890 Colt.ns Mountain Rd,Chapd Hill,NC 27516
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 3s 862 68 91-79.224505
PARCEL#(S): 95786;95966;95967;95968;95969;95970;95971;95972;95973:1212
TOTAL DISTURBED ACRES or SQUARE FEET: 4 57 AC
PURPOSE OF ACTIVITY: New gravel rued
FEE AMOUNT SUBMITTED: $2,500 RIVER BASIN: CAPE FEAR
"LANDOWNER(S) OF RECORD (attach pace 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: HONG TIEU NGO Phone: [phone]
Address: 6515 BURNING TREE OR E-Mail: Hong@ re.corn
HOUSTON,TX 77036 Signature:
"FINANCIALLY RESPONSIBLE PARTY (applicable only if different from propertvowner)
Name: Phone:
Address: E-Mail:
Signature:
NORTH CAROLINA AGENT(applicable only if either owner or financ4t a4onsible party does not
reside in North Carolina) w-�`�' 1Pi�t
Name: Carolina United Grading,LLC �a ,
Phone: [phone]
Address: 2732 Saxapahaw Bethlehem Church Rd. E-Mail: 9 ding.com
r din coin
Graham, NC 27253 Signature
ENGINEER/SURVEYOR EROSION CONTROL
00 any Name: Banemne Associates,PA Person to contact should erosion &sediment
`% dress: 221 Providence Rd.
control issues arise during land-disturbing activity:
Chapel Hill,NC 27514 Contact Person: HONG TIEU NGO
Contact Person: Lee Price Company Name: NA
Phone:[phone]
Phone: [phone]
E Mail: [e-mail] E-mail: m [e-mail]
Page 2 of 3
12/30/2023 3/30/2023
ANTICIPATED START DATE: ANTICPATED END DATE:

Soil Erosion and Sedimentation Control
cMi_n1 b..NI.4:COUNTY Financial Responsibility/Ownership Form
NOT Rv'QtI:IRED TO BE COMPLETED FOR RESIDENTIAL LOT PERMITS.
LEASE READ THE FOLLOWING INFORMATION:
I)This section must be signed in the presence ofa Notary.
2)This form must be signed by the property owner if an individual.If owned by a company or corporation,this form muslvtie signed by an officer,
director,partner,attorney-in-fad,or otherperson with authorityto execute instruments for the corporation and accmnNbi 4 by:;a complete list of all
partners,managing members and registered agents of thc company or corporation.
3)This form must also be signed by the financially responsible party and NC agent(if applicable).Same provisions oft(2 above apply.
4)If the landowner and financially responsible party are different,the completion and signing of this page shall serve as documentation
acknowledging the landowner consents to and authorizes the financially responsible party to undertake thc proposed land-disturbing activity on the
landowners 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 arc 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 Lrosion 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 Lrosion and
Sedimentation Control Ordinance.This penalty Is up to SS000.00 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: SONG TIED NGO
Company(if applicable):
Signature:
FINANCIALLY RESP NSIBL RTY (applicable only if different from property owner):
Name and Title:
Company:
Signature:
NORTH CAROLINA AGENT(if any):
Name and Title: Austin Adams-Owner
Company: Carolina tin d radinq,LLC
Signature:
***#****####*#*#*#* **************#*******************************
1, ", //LL an.. 7 ,a Notary Public of IQCY15 County in the state
Y�
of TQ)CQS do hereby certify that . ni i. ♦ Q personally
appeared before me this day and under oath acknowledged reading the informs ton abo 'and acknowledged that the
abode-f was executed by him or her.
Witness hand a d official seal,this the 2'55 day of t.Nt0- ,2O,)-
•
BA Till IRAN
xq.c�' it.=Notary Public.State of Texas
Notary P blic '/r / ?lyV,a Comm.Expires OA-30-2024
My co fission expires / �� ', y (SEAL)' %�O',`�` Notify ID 10454750
Page 3 of 3