NCC223106_FRO Submitted_20220902

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Applications may be smbniitW online:
hup://cha&=ow*mr.viewlwintclw coWeaUvriedIM
Land -Disturbing
Permit Application
Please include all required sisnatures. 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, plan, and fee requirements
apply to your project and then check one of the boxes below:
g) Land -Disturbing Permit. The following items are required to obtain this permit: completed
application, plans, deed, and fees. All clearing and disturbance must be included when calculating
disturbed area.
FeeRequirements:
See attached PERMITTING FLOW CHART
For fees that 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 00.
PlanRequirements:
Desiea 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
weboage. This plan must satisfy all loca.4 state, and federal minimum plan
General Plain: submit (1) copy of site plan showing proposed disturbance limits 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,
Residential Land -Disturbing Permit webpage. Complete table on sheet 1 ofResidential 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
Plan Requirements.
$100 flat fee
Site Plan showing property boundaries and proposed disturbance limits. The site
In aired b the Environmental Health D artment can be used as a base.
ALL CEMM MADE PAYABLE TO CHATHAM COUNTY
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Cl IATi lAM Cci ItjN-ry
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Land -Disturbing
Permit Application
"The mailing and street address of the principal place of business for the person/entity financially responsible and
the land owners) must be provided A P.O. box is NOT acceptable as an address.
**If the financially responsible person/party is different from the current land owner, an agreement signed by both
parties must be provided allowing the financially responsible party to conduct the land4isturbing activity on the
property.
PROJECT NAME: —'V- C
ADDRESS OF PROJECT:
IN
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 3 Xif rF3 . i �/ 79 yi 3 "t o. b I
PARCEL g(S): 00 b 2 2 `'I K
TOTAL DISTURBED ACRES or SQUARE FEET:
PURPOSE OF ACTIVITY: iJoa) 4",p em
FEE AMOUNT SUBMITTED: )53;57 .yy RIVER BASIN: CAPE FEAR
**LANDOWNEM OF RECORD (attach page to list additional owners)
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: mhn S. 5e S Phone: R t 61— 33.9
Address: _3 j / Car E-Mail: ei MoZt - Cowl
.P H��LE bar 7 &1 G signature: %B . .
Name. ¢
Address:
Phone. 6 7
E-Mail: aC e7^ a t ,"
Signature:
NORTH CAROLINA AGENT �applicab , oniv if own m or financially monsibl. - e MM does not reside in
North Carolina)
Name: Phone:
Address- E-Mail:
Signature:
ENGRgEER/SURVEYOR EROSION CONTROL
CompanyName. & [A Person to contact should erosion & sediment
Address: control issues arise daring land4hturbing activity:
Gontaet person: crai.9 Fox
Contact Person: rt/ A Company Name: Fa x G nP -gk lX&a c i "j'; -TN C -
Phone: Phone: _1336 — 2 64 -^ 6 3'1 f „J
E-Mail: E-Mail: _-COX!? C- i A no !I in gL. CCM
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AN3TCIPATEDSTART DATE. OG-tviyP.r' O��. ANTICPATEDENDDATE: ClC'l�obcr� T a�3

T -.1
�`- Soil Erosion and Sedimentation Control
CHATHAM CQLIpq A- r a c. A RO XJ Financial Responsibility/Ownership Form
N ts-a
NOT REQUIRED TO BE COMPLETED FOR RESIDENTIAL LOT PERMITS.
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 (2) years 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 (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:
Company (if applicable):
Signature:
ADDITIONAL
Name and Title:
Company:
Signature:
NORTH CAA
Name and Title:
Company:
Signature:
M
AGENT (if any):
T
Y(if any):
I, Qld a a Notary Public of �-- Q County in the state
of t''-� do hereby certify that 'r4 `°e) 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 t t'`S �' , 20_- -
C>L D rah D. ares'.�
Notary Public
Notary Public Chatham County
My commission expires`'" �'"� 2-''-�. } W 2.3 N CarolinaI - :1
Page 3 of 3

Soil Erosion and Sedimentation Control
Financial Responsibility/Ownership Form
f f ♦ f f ! i' ♦ f ,
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 (2) years 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 (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, attomey-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.
5) This form must also be signed by the financially responsible party and NC agent (if applicable). Same provisions of # 4 above apply.
OWNER OF PROPERTY: �?
Name and Title: j G A N S e G i1
Company (if applicable
Signature:
FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner):
Name and Title:
Company:
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
I, --. Q, n t e.e S &cLAr ir QA , a Notary Public of WQ,4;:@ County in the state
of N�o q„ro t`p� �_do hereby certify that .�p�n �� c Q `S.9T 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 t KI % �, 2Q A ff
�' S GAJJ, �i�A
AA ]An
°tks
y °
N t Public IetBUb
My commission expires 0 L° M -r Q' � 0� (SEAL) ,-. *-
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