NCC213679_Site Plan or Location Map_20210618

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Land -Disturbing
C'rtA'fIIIANt Uc [Iti I Y
Perntit Application
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I'leasL e:umplcte both pages of this font and return to: E-0—tofve Use:
Physical Address Mailing Address
80 Fast 5t_ PO Box 548
Pittsboro, NC 27312 Pittsboro, NC 273 b 2
Phone: [phone]
Please see Pi' RMITT1NG FLOW CHART to dctemiine which permit and plan rcquircments apply to
your P'roJecit and then check one of the boxes below:
® band-Dishrrbiing Permit_ The following items are required to obtain this perntit_ completed
application, plans, and fees. Land -Disturbing Permit applications must include all parcels, lots on
one appltcatlon with the total am nt of disturbance in acres for all par'cclflots_ All clearing and
disturbance must be included when calculating disturbed area.
Fee uircmenta:
Permit Fee: $250Jdisturbed acre
Plan Review Hce: $2.5_01disturbed acre - --
Fecs are rcxufdvd up to the next whole acre.
Example: 1 acre or le-m5 is $500, 1 Al-2 acres iti $i,Dt]U. and 201-3 is SI,500.
P] m Rcquireemts: -
Dcc r n Plan: submit ( 1) cony of an erasion control plan completed 8c scaled by a professional Land
surveyor, professional engineer, or registered landscape architect, This plan must mee the critena of the
Chatham County Erosion Control Plan Review Chtxklis-t and inchxle all applicable constriustion details.
These can be found on the Chatham CAmnty Watershed Protection wcbsite, on the Frosion Control
+ w a c. 'This tan must satic all Iocal, %fade, and federal minimum tan iremenLvi.
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 C'rener-al Plant can be found
on the Chatham County Watershed Protection websitc on the Rc;i&ntiai Construction webpage. Indicate
Lot drainagr patRean(h) on sheet I of the Residential (knerai Plan_
❑ Residential Lut Permit. The following items are required to obtain this permit: completed
application (ifrequinxi scc note 4 on PPR M 17T1N_ G_ FLOW CHART), , site plan, and fee.
ftn�irerrtents: Plan Raquir�cmcnts:
$100 flat fee Site flan showing property boundaries. The site plan required by the
Environmental Health or Central Permitting Dcpartments is sutitcient_
ALL CHECKS MADE PAYA1Rt.F TO CHAfI1AM C:Ot;NrY
Rage 1 of 3

Land -Disturbing
Permit Application
PR[ JFC.T NAMF: Wheal Res de DATE: �WQ5 l
ADDRFSS OF PROXCT: 143 Revmoru CXNC, Pit sbCCO
1.,A r r'r L'UJIULONCITUDE OF PROPERTY AT SITE Ira►-1'ttANCE. = 79.208, 35.782
PA RCF.I. #(S): 7&1A 7
TO'I'AL DIS-FURBED A[.RCSwSQUARE FEET: Gres
PURPOSE OF ACIrI V 1TY: new avtrwbon
FEE AMOUNT }USMTTTCD- 500 -
LANDOWNER(S) OF RECORI] (AAM h yagc to list additions] owner&
Please provide a oomplcte list of partners, managing members and registcrcd :trcnts if the responstbie entity or
land owner is a group of individuals, corporate orgaribmtion or entity.
Name: parker Wheat Phone: 6WOM366
Address: 10i Richardson R0. E Mait PWVM.vhea*yatgp,
! 101-1*. NH 03049 signature. � � � i� � *✓L
7It?.[
FINANCIALLY Rl.SPONSI13LE PARTY (goup>ble Orly if different fromgE2E� rtyowncrl
Name: 1'htine:
Address_
_- stgpat,rc:
NORT11 CAROi.1NA AGENT1 ho hic only if owner or financially responsible pafly dUer; oat ride in
North Carolina)
N:tme: Phonc: _
Addn:ss: E-Mail:
h.NC;lNEFRISURVEYOR
Company Nww: JVr'*1
Address: 314 Yo►ktown Drive
ChuW Hill, NC 27516
Contact Pemm: Malt-,arcf!II
phoa,e: 87'993.2029 3
E- 4aii: traverae'JOV" "I
simuttum
EROSION CONTROI.
Perin to contact should erosion & sediment
control issues arise daring land-disturbingartivity:
Contact Person: Jae: Krrnody
Campany Name: Attisokrte Coruuuctbcn -
Phnnc: &-82312MI
E-Mail: ]t'P ahF.cila,rpncxr�lr]erS-*�
Page 2 of 3

Soil Erosion and Sc-dimentation Control
CA i'[)tivtl
Financial Responsibility/Ownership Form
PI-EASF READ THH FOLLOWING INFOR MATIUN:
1) -Phis setietiatr must be signed in the ptescocc of a Notary
2) All Land-11isturbing pti'rrrnits are valid for up to (7) years from. the dale of iLcnance- if cirCunx%4.=LkM warrant, the permit may he
extended for (2) Yam% per the conditions of the ChWhain County Soil I-1—mm and Sodinicntabun Contmi Ordinance. Uprm wnitm
notice, the ]:Ind Ih%Mrhi nF permit 'ray be -vokod lot failure to comply with the Ordinate c. II' !hc permit is reroltxl. all other
permits and appruvals arc withheld until the propenty is owe main in compliance with Chadimn Comity trgulations. Alw, utxm
wTitrcn notice. a sovil penalty (fine) out be irwi},arcd against the progl7ty owner andl x additional f n=LzOly t %Mr-siblc party (if ray)
far ❑iolatiorks of the Chalhant Cututry Soil Fnxcion and Scdimrntatiun C'rmtrol Ordinwcc. This paanalty ns Up to S5000.00 per Np-lobinon
per day anti is-L-Sesscd daily for crer► day the property is in ti•u)Wton Interfering with or haarpertny an inspoctioa can miult to a civil
pumalty without written rouse.
;.i The infomiation prnvuW on this form is true xnd comet to the blest of my knowkdgc and belief wO wax pmwided by me while
u ndc--r uNoh
41 This him-m mW be sig not by the irrnprrt}• vwlxf if an individual. IFowned by a conslxury of Lorlxxafinn. this form rnW he si1atLNd
by :ur officer diroctof, pwtjtl7, aurrmrw-in-fact, or 0lhL7 perarm with authority IU cAmute nnstrumenu for the corpofad-mt :uxl
accompanied by a cotnpllyc list af'all psRnrrs- rtrwasing memhtT% and rcgistcrad ageoTs of the company nr corporutiva
{lVf NER OF PROPERTY:
Nat= and Title: Pater WNh al
C'k'tnipany (ifapplicab1c):
Signature:
ADDITIONAI
Name and 'rink:
Company;
Signature_
F'iNANCIAI LY RESPONSIBLE PAR (ifanvy
NORTII CAROUNA AGENT Cif any):
!,Lame and 'rrtlC:
Company: -
sipoturc:
,FI
1. f a Notary Public of �`- 3IIS�x }'✓ . � County in the state
Of hcrehy ccriify that L�Z' - pt-rxmaliy
appeared hofive me this day and a ndcr omb acknowledged reading the information ahore :ind acknnwlptje.ed that the
abovc form was executed by him or Iva,
W css my hand and of vial seal. this the��day of���� r ']
r
N at� Puirlic Jv
Conuumsion expitLl
page 3 of 3
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Store al 1`4NN FIarrshire -
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