NCC241376_FRO Submitted_20240506

Check if this project is ARPA-funded "'
Attach a copy of the Letter of Intent to Fund
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act, including any
activity under a common plan of development of this size as covered by the NCG01 permit, before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A. o .../ /// /1
/ v Z
1. Project Name (,
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County act_ Atfl1 City or Township PAISIO/D
Highway/Street R'(4(4.VY5 Kj• Latitude)decimal degrees) 557 ALongltude(decimal degrees) 7/ .17!
3. Approximate date land-disturbing activity will commence: b/(/; y
4. Purpose of development(residential, commercial, industrial, institutional, etc.): / Pagiiir4(
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): ' 33
6. Amount of fee enclosed: $ l Q 0 . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes Enclosed /No
8. Person to contactshould erosion and sediment control issues arise duringt / land-disturbing activiittyy. /�
Name "� ,Ill PE'i'5(, `I E-mail Address {r/1'`/ dow/ 444 11.4,iCt,•cd A
Phone: Office# N/4 Mobile# (4/0 Vd7.-996/
9. Landowner(s) of Record (attach accompanied page to list additional owners):
PA 'c°( 4- /24rei (Vi)2v'l>?
Name Phone: Office# Mobile#
al
k'otp 7d7x,,64./79 ra,
Current Mailing Addres Current Street Address
ens k� .2T3/a Piedili" /6 273/Z
City State Zip City State Zip
10. Deed Book No. 0I1/O Page No. 107 f Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s) of the owner(s)may be listed as the financially responsible party(ies).
(% y4A 1444 A [iCPc LC ,g7/e c44c7ex 4,001fi 44, y,
Company Name E-ma' Address
O. ilax 740'( 1 Q s7-
P
Current Mailing Address Current Street Address
161 . A/ 2Z27ff Rilf�� � era'
ity ('ViState Zip ity StateZip
Phone: Office# )1. / /+i'2 Mobile# (4/1 7�p—f!�/v /
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate f Assumed Name.
C OI l'l VJ � i�Ps �
Company DBA Name
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
tJ 1/ 1rccL 6eer4( h#n ys.e,
Type or pri me Title or Authority
1/ --.4./2"‘f
Signature Date
I, O1
�.J el'
Jv a Notary Public of the County of ��, I/(5�
7
State of North Carolina, hereby certify that V / (;/ii'L f'(r Lil appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this L day of 1/ j , 20 7
A
•
n c, - a/1>1 jij' ')/o-f ry �N
DANIEL MISNER 077(7
i�
Notary Public My commission expires Uv
Alamance Co.,North Carolina
My Commission Expires Sept.2,2026

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#

WATERSHED PROTECTION DEPARTMENT
80 East Street
CHATHAM COUNTY Pittsboro,NC 27312
°K I " ` '`H O' '\ Website:chathamcountync.gov
Office:[phone]•E-mail:taylor.burton(dchathamcountync.gov
Soil Erosion and Sedimentation Control
LETTER OF APPROVAL
April 30,2024
Daniel A. Pasek
78 Blacktwig Road
Pittsboro,NC 27312
Project Name: Saralyn—Lot 14
Project Number: WP-24-121
Acres Approved: 0.33
Submitted by: David E. Cates
Date Received: 04/03/2024
To The Above Named Person(s) and/or Entity,
This office has reviewed the subject erosion and sedimentation control plan. We find the plan to be
acceptable and hereby issue this Letter of Approval.
Erosion and Sedimentation Control Plan: This plan approval shall expire (2) years following the
date on this Letter of Approval, unless a Land-Disturbing Permit has been obtained within that initial
two-year period and remains in effect as provided in Section 164.12 (H). Active sites may have the
permit renewed by applying for renewal 30 days prior to expiration.
Section 164.10 (L) of the Chatham County Sedimentation and Erosion Control Ordinance requires
that a copy of the approved erosion control plan be on file at the job site.
North Carolina's Sedimentation Pollution Control Act is performance-oriented, requiring protection
of existing natural resources and adjoining properties. If, following the commencement of this
project, the erosion and sedimentation control plan is inadequate to meet the requirements of the
Chatham County Sedimentation and Erosion Control Ordinance, this office may require revisions to
the plan and implementation of the revisions to ensure compliance with the Act.
Acceptance and approval of this plan is conditioned upon your compliance with county, state and
federal water quality laws, regulations and rules. In addition, local city or county ordinances or rules
may also apply to this land-disturbing activity. This approval does not supersede any other permit or
approval.
Inspections: This letter gives the notice required by G.S. 113A-61.1(a) of our right of periodic
inspection to ensure compliance with the approved plan.
Section 164.12 (I) of the Chatham County Sedimentation and Erosion Control Ordinance requires
self-inspections and monitoring for all sites receiving a Land Disturbing Permit. These inspections
can be done by the Financially Responsible Party, or an agent thereof. These inspections must occur
at a minimum of once a week and within 24 hours of any rain event of 0.5 inch or greater. Copies of
inspection records and reports must be kept on site and produced to Chatham County upon request.

NPDES General Stormwater Permit NCG010000: Please be aware that your project will be
covered by the new NPDES General Stormwater Permit NCG010000 (Construction Activities).
You must apply and receive the NCGO1 Certificate of Coverage electronically at the following
website: https://deq.nc.gov/NCG01. The Electronic Notice of Intent, or "e-NOI form",
link is used to complete this step. After you submit a complete and correct e-NOI form, a
Certificate of Coverage will be emailed to you within three business days. Please direct questions
about the e-NOI form to the Stormwater Program Supervisor of the North Carolina Department of
Environmental Quality's Division of Energy, Mineral, and Land Resources. Contact information is
available on the"Contacts"page of the above-referenced website.
This form MUST be submitted prior to the commencement of any land disturbing activity on the
above named project. If a construction activity that disturbs 1 acre or more (or is part of a
subdivision or other common plan of development) fails to submit an e-NOI after the approval of its
erosion and sedimentation control plan, then the permittee is in violation of federal permitting
requirements and could be subject to penalty assessment.
Please also be aware that you are required to provide updated information, in the event
circumstances change regarding your project, to the North Carolina Department of Environmental
Quality's Division of Energy, Mineral,and Land Resources by filing a"Modification Form".This can
be found at https://deq.nc.gov/NCG01.
Land-Disturbing Permit: A Land-Disturbing Permit will be issued by Chatham County only after
the above-referenced Certificate of Coverage is provided to Chatham County. Construction activities
can begin only after the Land Disturbing Permit is issued. Active sites may have the permit renewed
by applying for renewal 30 days prior to expiration. Chatham County's Land-Disturbing Permit must
be posted at the job site once received.
Please note that this approval is based in part on the accuracy of the information provided in the
Financial Responsibility Form, which you provided. You are requested to file an amended form if
there is any change in the information included on the form. Please notify us when you would like to
schedule a preconstruction conference. Notification shall be given at least 7 days prior to initiation
of activity.
Respectfully,
Taylor A. Burton
Senior Watershed Specialist
Chatham County Watershed Protection Department

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Prepared By OWYANE LATE. VERDUGO TRUSTEE SERVICE CORP PO DOx 10003 HAOCRSN)WN•fan
2174 7-0003 1400-283-7918
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SATISFACTION OF SECURITY INSTRUMENT
ITtUORTGAGE.INC a 112300i 7e9'PASEK'Lenas• 00554,1 7162C6942 Cheii'em ficlh Carolina
The under1.gled is now the Iienhoider in the Security Irsiru me nl WOnticed as follows'.
Type of Security Instrument.Deed of Trust
Original Grarltor(s) DANIEL A PASEK
Onglnat Secured Perty(.es) MORTGAGE ELECTRONIC REGISTRATION SYSTEMS,INC
RecorOng Data The Security Instrument Is recorded 04/30/2013 In 0ookJReel/Ld»r:01083 Pave'Fcho 001n as
Instrument No.:05114 In the office of the Register of Deeds for Chatham County,North Carol tier
Property Address 78 BLACKTWIG R0,PI^SBORO.NC 27312. 478
Th.s Satisfaction terrrnales the erectiveness of the se urfly Instrument
CITIMORTGAGE.I V C
On July 27th 2015
By.
SHAWN LYERLY President
STATE OF Maryland
COUNTY OF Washington
On this 27th C3y or July 2015.bebre me.the undersigned officer I.r•sonal y appeared SHAWN LYERLY,who made
acknowledgment on behalf of CITIMORTGAGE.INC..who acknowledges h mse It herself to be the Vice President of
CITIMORTGAGE,INC,a corporation.and that he/she as such Vice President being authorized so to do,executed
the roregang instrument for the purposes therein conla,red.by signing the name of the corpprptiOn by
himsetfherselt as Vice President and acknowledged the satis'achon cf tna above-referenced Deed of Trust.
WITNESS my hand d of5 at
Jwslee Swayer
JESSICA L SCHRO yya aNnokfrtgary Public
Notary Expires.02/222017 yr6saestilT Co.MO
Vntrw.72.lalr
(Th4 area r nolanol seal/
When Recorded Return To DANIEL A PASEK,78 BLACKTWIG R0,PITTSBORO,NC 273124478
T••r.'xiit.er"'gMG.1+.wCAWenYpk0r1100k!l4UI/.rIUAII.•.IA'14C.Mni•1.7n01rtt NCsrAIC.InUti•cLL,_area cn..•
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CHATHAM COUNTY u t
NORTH CAROLINA 3
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Losemg Om Chris to
•Smallher Grtlnn+
CHATHAM COUNTY
AUTHORIZED AGENT FOR FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 6495 PARCEL ID(PIN) PARCEL SIZE4.976
STREET ADDRESS: 76 Blacktwig Rd, Pittsboro NC
Please print:
Property Owner: Daniel Pasek
Property Owner:
The undersigned owner(s)of the above described property,do hereby authorize
Will Perschau , of Charles Woods Builder LLC
(Contractor/Agent) (Name of consulting firm if applicable)
to act on my/our behalf and take all actions, I/we could have taken if present,necessary for the processing, issuance
and acceptance of reviews, inspections,or permits and any and all standard and special conditions attached to
these approvals.The activities authorized include the following(Check all that apply):
0 Check here for all of the below options.
Building Permit
Zoning Compliance Permits
Floodplain Determination
Soil Erosion& Sedimentation Control Permit
fl Permits to install,repair,evaluate,or expand onsite wastewater system(s)
Evaluation/inspection/permitting of a private drinking water well(s).
✓ Riparian Buffer Review pursuant to §304 of the Chatham Co. Watershed Protection Ordinance.
Other:
Property Owner's Address(if different than property above):
78 Blacktwig Rd. Pittsboro, NC
Telephone: [phone] E-mail: [e-mail]
We hereby certify the above information submitted in this application is true and accurate to the best of our
knowlgli rW/4. Pase,F
tOKSIGN UMW 1S16ZWYO
Owner Authorized Signature Agent Authorized Signature
Date: Apr 22, 2024 Date: Apr 22, 2024
Rowicorl 1 ohm 7