NCC216713_FRO Submitted_20211203

C H 1 It I -I - - A
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
DEPARTMENT OF SOIL EROSION & SEDI_MENTATION CONTROL
A Land -Disturbing Permit must be obtained before initiating any land -disturbing activity which
will exceed ( 1) acre (43,560 square feet). A Land -Disturbing Permit Application, this Financial
Form, an Erosion and Sediment Control Plan, plan review fee. and permit fee should be submitted
30 days Prior to the planned commencement of the land -disturbing activity.
The above information should be submitted to: Jim Willis
Soil Erosion & Sedimentation Control Dept.
P.O. Box 130. 80 East Street
Pittsboro, NC 27312-01 30
Please type or print the following information:
Date: 11124/2021
Name of Project: Pennington Lot 31
Location of Project: 61 North Julip Court, Pittsboro, NC 27312
Acreage to be disturbed: 0.66
Purpose of activity: Construct one single family home
Landowner(s) of record:
Name: Meredith Vanterpool
Address. 5304 Arete Way
Raleigh, NC 27607
Telephone: Home 919-271-2775
Office
Fax
E-Mail meredith.vanterpool(cDgmail.com
Name:
Address:
Telephone:. Home
Office
Fax
E-Mail
Indicate Book and Page where deed or instrument is filed.
02161 0209
Book
PIN# 14277
Page
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. 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. If the person financially
restionsiblc is not a resident of North C'arolhia. a *forth Carolina seem uw,t he designated. If someone
other than the owner is financially responsible, their signature is required below also
Meredith Vanterpool
Name of individual
NC agent's signature (If applicable)
Title and Name of Company Additional Financially Responsible
�� Party (If applicable)
4 � v
()r� 1C-sSi-nattire'

PLEASE READ THE FOLLOWING INFORMATION:
All Land -Disturbing permits are valid for up to (2) years from the date of issuance. If
circumstances warrant it, the permit may be extended for (1) year per the conditions of
the Chatham County Soil Erosion and Sedimentation Control Ordinance. Upon written
notice, the Land-Disturhim-, permit may be revoked for failure to comply with the
Ordinance. II" 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 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.
STATE OF SI G O 'NEJR'S, . IGNATU1 E
COUNTY OF a_ _ ",
t 'r
I, , ,/AKajfl , a Notary Public of said County and State, do
hereby certify that Me Yfti personally appeared
before me this day and under oath acknowlei uccl.reading the information above and
acknowledged that the above form was executed by him or her.
Witness my hand and official seal, this the ZN day of
202-1
H M❑
e.�
My Commission Expires:
= Notary Public
�'❑.�A�y.�y •'=
(SEAS.)
ry1
STATE OF
s,�9F . ARY
c[3�>ir3� financially responsible party)
�►,,,j"►
COUNTY OF
111111010
I, , a Notary Public of said County and State, do
hereby certify that personally 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.
Witness my hand and official seal, this the day of , 20_
My Commission Expires;
(SEAL)
Notary Public