NCC242007_FRO Submitted_20240702

CIIATI-IANI CC)LINTY
N () IL I' 11 C A It (3 1 1 N A
Soil Erosion and Sedimentation Control
Land-Disturbing Permit Application & Financial Responsibility/Ownership Form
The Property Owner, additional Financially Responsible Party and North Carolina Agent do hereby agree to comply with all
applicable Chatham County Regulations pertaining to development if a Land-Disturbing Permit is issued. The Property Owner and
additional Financially Responsible Party furthermore, do hereby agree to be responsible for the tinkly installation and maintcnancc of
erosion/sediment control devices throughout the duration of the project.
Please complete both pages of this form and return to:
Rachael Thorn
PO Box 548, 80 East St.
Pittsboro. NC 27312
Phone: [phone]
PROJECT: r Ca\-.7- 4\ DATE:
LOCATION OF PROJECT: �. �:.� --� e -) • C.- 3
TOTAL ACRES IN TRACT: O . 5'1 PARCEL #: g3m C
TOTAL DISTURBED ACRES or SQUARE FEET: 0-
PURPOSE OF ACTIVITY: ,I.AM iCk\-kAd PAQ
OWNER OF PROPERTY
Name: -i% Li `'} i Phone:
Address: Sid�'\ &\ E-Mail:
X, i �� ' �-- Signature: 10.0:4K
FINANCIALLY RESPONSIBLE PARTY applicable only if diffe nt from property owner)
Name: Phone:
Address: E-Mail:
Signature:
NORTH CAROLINA AGENT (applicable only if owner does not reside in North Carolina)
Name: Phone:
Address: E-Mail:
Signature:
ENGINEERJSURVEYOR
Company Name: Phone:
Address: E-Mail:
Signature:
Contact Person:
Page 1 of 2

C[-IA l-IA 1vl CouN-r,Y
N () it I' II C A lZ C) I I N A
*This section must be signed in the presence of a Notary in order to be processed*
PLEASE READ THE FOLLOWING INFORMATION:
All Land-Disturbing permits are valid for up to (2) years from the date of issuance. If circumstances warrant, the permit may he extended for ( I ) year
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 (tine) 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 S5000.00 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.
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.
OWNER OF PROPERTY: This form must be signed by the property owner if an individual. If owned by a company or corporation, this
form must he 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.
Name and Title: N �c 0 \.10 1 AL.
Company: C-14 >fc V L- 'sU &--- 1 .L C___
j
Signature: r' �' �� - ' °
ADDITIONAL NANCIALLY RESPONSIBLE PARTY (if any):
Name and Title:
Company:
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
Nkl,M0 , a Notary Public of ki0 'N1C:. County in the state
do herebycertify that;4 �� v personally
of — C[ IU . C)C) ---
appeared
before me this day and under oath acknowledged reading the information above and acknowledged that the
above form was executed by him or her.
104
1 this the t day of , 2Q `��r��tN��Nh
Witness my hand and official seal, fr
MCA�/ ,'P,,n \ n1lSslpn• s •
f�L s
•
:Z t4OTAR y it. i
Notary Public
12-r (SEAL) pve>~�c
My commission expires al
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0
#9 ...•r /7/202�••. ��.•.
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