NCC216036_FRO Submitted_20211029

CHATHAM COUNTY
N O R T H C A R O L I N A
Soil Erosion and Sedimentation Control
Permit Application
Please complete both pages of this form and return to:
Physical Address Mailing Address
80 East St. PO Box 548
Pittsboro, NC 27312 Pittsboro, NC 27312
Phone: [phone]
For Office Use:
Please check one of the boxes below for the permit that you wish to apply for:
❑✓ Land -Disturbing Permit: This permit is required for the following activities: (1) all new commercial, land
clearing/development, and non-residential projects greater than 20,000-ft2 and construction of all new residential dwellings
greater than 25,000-ft2 of uncovered or disturbed land
a. The following items are required to obtain this permit
i. Two copies of an erosion control plan which was completed and sealed by a professional land surveyor, professional
engineer, or registered landscape architect. This plan must meet the criteria provided on the Chatham County SESC
Plan Review Checklist and must include all disturbance and clearing for the project including driveways, yards, and
septic systems for residential projects.
ii. A permit fee of $250/acre of disturbance and a plan review fee for $250/acre of disturbance. These are rounded up
to the next whole acre. Example 1 acre or less is $500, 1.1-2 acres is $1,000, 2.1-3 is $1,500.
❑ Multi -Lot Residential: This permit is required for all multiple lot construction in the same subdivision by the same builder that
cumulatively disturbs greater than 25,000-ft2. All submittal requirements are the same as the Land -Disturbing Permit listed
above.
❑ Residential Lot Permit: This permit is required for all disturbance related to home building activities that do not exceed 25,000-
ft2 of disturbance. This disturbance must include driveways, yards, and septic system clearing. The following required submittals
must be submitted to Central Permitting when you apply for your Building Permit.
a. The following items are required to obtain this permit
i. A plot plan showing clearing boundaries and approximate location of the areas listed above must be included. This
plot plan is not required to be completed by a surveyor or engineer.
ii. A permit fee of $100 must be paid to Central Permitting when you apply for your building permit.
Should you have any questions regarding the above permits or required submittals please contact:
Land Development/Commercial Projects
Morgan DeWit, PE
Senior Watershed Specialist
919-542-8268
[e-mail]
Residential Lot Permits
Robyn Wharton
Watershed Specialist
919-545-8344
robyn.wharton @ chathamnc.org
Residential/Multi-Lot Residential Projects
Drew Blake
Watershed Specialist
919-545-8394
[e-mail]
Page 1 of 3

AY N Ccaury _.�
Soil Erosion and Sedimentation
N R H C A% 01 L I� Permit Application
PROJ CT NAME: 80G - Blumentals DATE: 9'2/21
LOCATION OF PROJECT: 23118 Umstead
PARCEL #• 66806
TOTA DISTURBED ACRES or SQUARE FEET: 27,733 sf
PURPOSE OF ACTIVITY: New single family residence 6L+�
FEE A WOUNT SUBMITTED:
($250/a.cre plan review fee, $250/acre land disturbing permit fee)
LANDOWNER(S)OF ',ECORD attach pa e to list additional owners
Name: Mario Gorziglia & II -se Blumentals Phone: [phone]
Addres : 56703 Nash E-Mail: marioilse044@ mail.com
Hill, NC 27517
Name: IBOLD Construction
Addres : 50051 Governors Dr Suite A
Chapel) Hill, NC 27517
Name
ENGINEER/SURVEYO
COmpar y Name: Nau Compa iy
Address: PO Box 810
Rolesvi le, NC 27571
Contact erson: Brian O'Ka e
Phone: [phone] ext 6
E-Mail: bokane@thenauco. o
Signature:
TY (applicable only if different frc
Phone: [phone]
E-Mail: sheen@boldnc
_ Signature:
if owner or f
Phone:
E-Mail:
_ Signature:
not
Person to contact should erosion & sediment
control issues arise during land -disturbing activity:
Contact Person: Jason Schurr
Company Name: BOLD Contruction Inc
Phone: [phone]
E-Mail: Jschurr@boldnc corn
Page 2 of 3

Soil Erosion and Sedimentation Control
N�Rr 1-1 C A n ID 1,1NA
Financial Responsibility/Ownership Form
PLEASE READ THE FOLLOWING INFORMATION:
1) This section must be signed in the presence of a Notary
2) 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 (1) year per the conditions of the Chatham County Soil Erosion and Sedimentation Control Ordinance. Uponwritten
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 Erosion and Sedimentation Control Ordinance. This penalty is up to $5000.00 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.
3) 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.
4) 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 -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.
OWNER OF PROPERTY:
Name and Title: Mario Gorziglia & Ilse Blumentals, Owners
Company (if applicable)
Signature: &KL.';jA &0//
ADDITIONAL FINANCIALLY RESPI7NSIBLE PARTY (if
Name and Title:
Company:
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
1, 2.t M-e' , a Notary Public of County in the state
of do hereby certify that ersonally
appeared be re me this day and under oath acknowledged reading the information above and acknowledged that the
above form executed by him or her.
Witness y and official seal, this the_2j day of L 20 fL.
Notary Public V 11
My commission expires ' % ' /_11--
AFSHIN HOSSEINPOUR
Notary Public, North Carolina
lip, Orange County
My Commission Expires
April AT2 2)
Page 3 of 3

C.F A-r
N K) R
1) This
2) All I
extends
notice,
permits
written
for viol
per day
penalty
3) The i
under o
4) This
by ano:
accomp
OWN'
Name,
Compa
Signatu
ADDI'
Name
Compa:
Signatu
NORT
Name a
Compai
Signatu
I Afshin
of N Car
appeare
above R
Witnei
Notary I
My com
_ram•-- �,_
A. -Lt .
y Soil Erosion and Sedimentation Control
Financial Responsibility/Ownership
Form
PLEASE READ THE FOLLOWING INFORMATION:
d in the presence of a Notary
section must be signc
and -Disturbing permits
for (1) year per the
are valid for up to (2) years from the date of issuance. If
conditions of the Chatham
circumstances warrant, the permit may
he Land -Disturbing permit
County Soil Erosion and Sedimentation
may be revoked for failure to comply with the Ordin
Control Ordinance. Upon wriat
ince. If the permit is revoked, all
and approvals are wi
otice, a civil penalty
hheld until the property is once again in compliance with Chatham
(fine) can be instigated Idditional
other
County regulations. Also, upol
tions of the Chatham
against the property owner and/or
County Soil Erosion and Sedimentation Control Ordinance.
financially responsible party (
nd is assessed daily
for every day the property is in violation. Interfering with o
This penalty is up to $5000.00 per vio
hampering an inspection
ithout written notice.
can result in ;
formation provided
th.
n this form is true and correct to the best of my knowledge
and belief and was provided by me wh
orm must be signed by
icer, director, partner,
the property owner if an individual. If owned by a compo
attorney -in -fact, or other person with authority to
ny or corporation, this form must be sib
vied by a complete Est
executc
of all partners, managing members and registered agents
instruments for the corporation and
of the company or corporation.
R OF PROPE
TY:
d Title:
y (if applicable):
e:
IONAL FINANCIALLY
RESPONSIBLE PARTY (if any):
d Title: Jason Dell
- President
y BOLD Constr
n
e:
CAROLINA AGENT
(if any):
d Title:
y:
e:
osseinpour
Ana
a Notary Public of Orange
County in the sty
do hereby certify that Jason Dell
personally
before me this dai
T and under oath acknowledged reading the informatic
n above and acknowledged that the
r was executed by
him or her.
hand and official
seal, this the 28 day of October
2021 ,
�AFSHIN FOSSEINPOUR
is
Notary Publ
c, North Carolina
ssionexpires 4-2
Oran
22 My CoAmprl
e County
#oon�Expires
Page 3 of 3
be
n
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ation
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