NCC243281_FRO Submitted_20241025

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Land-Disturbing
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."*t K I 16 I FI cSe4 tA t 1 Yz; A:"a Permit Application
Please complete both pages of this form and return to:
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 and plan 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, and fees. Land-Disturbing Permit applications must include all parcels/lots on
one application with the total amount of disturbance for all parcel/lots. All clearing and disturbance
must be included when calculating disturbed area.
Fee Requirements:
Permit Fee: $250/disturbed acre
Plan Review Fee: $250/disturbed acre
Fees 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 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 on the Residential Construction webpage. Indicate
lot drainage pattern(s) on sheet 1 of the 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. The site plan required by the
Environmental Health or Central Permitting Departments is sufficient.
ALL CHECKS MADE PAYABLE TO CHATHAM COUNTY
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Lailititistoiching
Permit Application
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6'1 he mailing nod street addrois of the principal place of business for the Imrsoiderdity financially responsible and
the land ovvocrOd most ite provided.A P.O. box is NOT acceptable as no address, [
'-'11 the financially responsible per:ion/party in different from the current land owner,.on agreement sigued by both
part ost he provided allowing the financially re:wow:ado party vermin to conduct the land-disturbing act;vity on
the propafty,
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PROJECT NAME: ( "lapellIfdge Lot 234-6 DATE: 10/4/2024.___...
AormESS OF Pltattikri':.15prandon Pines _,.. ___
LATITUDE/LONGITUDE OF PRO ERTV AT SITE ENTRANCE: 35.79147/-79,21721_
PARCEL/I(S): 81764
TOTAL DISTURBED ACRES oc SQUARE FEET: .42 i
PURPOSE OF ACTIVITY: NOW sFA_
FEE AMOUNT SUBMITTED:
"19xAND,QWNA„.743.1SLOF KKORD illtiCsh...M0 to_lbst additional owners) L
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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: David L.Acheson&Sarah E.Acheson phone: [phone]
Address; 116 Roslin Way Holly Springs NC 27540 E...maii: ,,,Sel, - , q hoo,tom-
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Signature:
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FINANCIALLY RESPONSIBLE PARTY(applicable only if different from property owner)
Narne Prowin-Douglas Custom Homes ...... phone: 919,669.1969
Address 2500 Regency Parkway Cary NC 27518 E-mail: emmaeprowitt-doughz,com _ [
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Signature: ,
h(21011 CARDLIkstA_AOENT(appligal le only if,pwrt r or(Manch By r spgnsible iuty.ths not reside in
North Carolina)
Name:) Phone:
Address: E-Mail:
Signature: _ a
ENOINEER/SURVEYOR EROSION CONTROL,
Company Name: i t , Person to contact should erosion &sediment
Address: 2,„:;,,,...1 ‘h.LC:::!:,,,„„„'---_,AILZ,1 0: control issues arise during land-disturbing activity:
Contact Person:
Contact Person: n CI:,,), i_ Company Name:,, (..:';„k-`:,,t 4,-+- - ,,,,,jhq,„t/t\l,e,—;-=
Phone: -1, . ,--%, ___ Phone: 'A','1 '' '-'"' ''''' ' ' :'
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E-Mail:IT:eani.c., ILL--,L.P.„L: c(,)k-k E-Mail: f0/3 I hh - !i2A,YiNV:.
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,...„--- -- SOH Er OS6111 Mind Setiiilleidation Control
a„1 IAA I ,lk Pvl 4I bV lllr,l r V
t I A Pl II 5. 141MCMCial Rennonsty/Ownership Form
NoT RiV(//i0,3) 70 111,f,( OMPI,F77,,7)1,01?1?It'Sl 7')1,3\1114 I,IX)) Ph7M/111S,
PUYAS1-;: Kri.1)0"1111-!;1..,'QUAlWiNcilMEQBMA:11;034;.
0 This section illOSl he Sirui:d in the presence ol a Notary [
2) Al) kand-Distiobing permits arc valid for up to (2)years from tho date of issuance, If circumstances warrdirt, the va-ruit nay he l?.
extended for())years per the conditions of the Chatham County Soil Erosion and Sedimentation Control Ordinance, t 1pon written [,
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notiec, the Lad-Distothing peimit may be revoked for failure to comply ‘villi its.: Ordinance. If the [mann is luOki,,;(l, all olll,Or
permits and approvals are withheld Willi tiv; mopeny is once again in compliance with Chatham County regulations. Also,upon .i.
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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 Comity Soil Erosion and Sedimentation Control Ordinance,This penalty is op to$50i10,00 per violation r
per day and is assessed I laity for every flay the property is in violation, Intotlering with or hampering an inspection can result in a civil
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penalty without written notice.
3)The information provided on this form is tine and correct to the best of my knowledge and belief and was provided by we while
under oath,
4)'fins form must he signed by the property owner if an individual. If owned by a company or corporation,this form roust bc signed
by an officer, director, partner, attorney-in-fact, or other person with authority to execute insirmilinits for tIKI corporation and
:tccompanicd by;I complete list of all partners,managing members and registered agents of the company or COrporation.
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OWNER.OF PROPER'IY:
Name and Title:_David L.Acheson & l!'Sarah E Acheson
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Company(if applicabk • i,
Signature: ____ l'.
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY(if any):
Name and Title: Jim Prewitt - President
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Company: - , - 1 • S C • I 11 •II- Is ;
41. )11 -
Signature: - "„ :' ' L
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NOIITII CAROLINA AGENT(if arty):
Name and Title:
Company:
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Signature!
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(
,a Notary Public of \:).CI'' 1 r';.;)r.)'{'i County in_thes411e-,
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of -,---,,---.(4-1(,.,,c,-A
t-,:,-,,,L --,,,-r-,, ,,,, rt.0, ,v,L do hereby certify that ',A,y'v',.6 f,1"Iv''''2' ,,($. -i:fgr,,r,_. ,..,,--(- - personauy— .,.‘ ,
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.
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Witness my hand and official seal,this the __11____ day of Jfl....''; it",:'/- ___,20.:,A1,.. 1,
146tary Public
1 r.'..so.ox7-,uoissiww09 4ini ,
My commission expires :,„z' z 41-10N
itqunoo uo;stILICT
onend,I,Jvi.oN
3):100Vi 7-.1 VVVk9 [!Page 3 of 3
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