NCC223258_FRO Submitted (2)_20220916

cz-iAp-t,kt)y v
rk A i 14 t- A to is Y. 1 K A
Land -Disturbing
Permit :application
Please wmplrtc both page of this form and return to, For. 0fF I; ;
Physical A61rass M ai I i ng Address
W last St_ PO Box 54
FittsNvo, NC 27312 13-ittsboro, NC: 27312
Phone_ (919) :54S-9269
Pieame sw PF.RMTI'T'11 G T-T OW CHART to dctam3inc which permit and Plan rcqui.rments appty to
your projoct and aiem check om of the boxes Mow:
lean&Distui-Nag Permit, The fuj1 rvwmg it= are rcquiroi to obtain this permit, compkted
aMlieation, plans and fee..%_ Land-Distarbi ng Permit applications m mt include all parcolsR.Ols on
cme application with the toil amov,t of disturbartw Rw -a11 pguxlAots, All elearia�g and disturbance
inust be included wh-ea caleulatin disturbed area_
Fee Req uiremt,11 Li=
Permit Fec: 9:2501dismw&od acre_
Plan R �r :w F : S25(Vd3 sWrbcd -acrc
Fees ate rounded up to the riat wh,oie -m.
Example, 1 acre: or less is S500, 1.01-2 acres is I ,N)OM and 2.01-1 is $1,5W_
Plan REquirernents:
Desiyn flan: submit (1) copy of an erosion control plan completed & sealed by a prul si"al land
%urveyor, prni'essicmal eftgiTteer, oT regiat+xcxl landsuWQ ardhitcvt. This plan must meet the criteria of the
Chatham (:ounly From-m Cuntrul Plain F,.uviM Chal list anal in-clude all applicable construction deals_
These can be 1 Ound ern the: C hatbam County Wa-mhud Protoch kn website, on the Erosion C-cmtmi
webp�_ lhi:s pl?, rapt tisJ'y ail local, state, and kd ra.l mkimum Plan requirements_
Gi rtac d Mg.* submit (1) copy of site plan along with the Chatham County ResLdential Genem1 Plan, Site
plan is Mt Mquired to be cumpleled by a do profcssimal_ The residential Crcneral p Ian can be found
on the Chatham County Wat hed PrCatection website ou the Rr idonU Cmstnwfion wcbjmgc. Inch -Cate
lut drainago pattcrn(s) ern sh m i of the Reslidential General ?Ian -
El ][ esid anal ]Lod Permit_ J he foflowin.g items are wired to obL-16n thib perTniL, VjTupli�tod
appJ ieation, site plan, and fee_ PAUE? 3 "F INANC'TA T, RF+DNSjB]L jTY/O 4NERSHIP FORIf
not rquired_
H'� i rrtrn�►rtc; P1A11 1 i.r#CtiE�lCS: - -_ _
$ l W flat fee SJ le Plan bhuwimg pzupurty bowmdHirics. The site plan rcquB-ed by the
J nvi rnnmentai Health or C enUW PermiWmg Departments is suflkicHt.
A [_I. C_HFA X% MATiF. PAVART.F. 7G C'H ATWAM CO fNTV
Page 3 of 3

L and-Di-s ]rbing
f A AT A AAA C C?1tiI�CT�' I}L'i'ttilt Application
*' The mailin g end street address of the prindpg 0 place of bum ness for the. per!on; er1#ity finxutlailti- rospunxih}r a n d
the Land owner(s) must li-e provided. A PA). hmx k 1 (Yi- acceptable as an address.
*elf the f -naneially r p0nsibj-r pvrsow party is difjrereut front the curma l-and OWik r. Un agreement signed by hoth
parties must lxe proyidcd allflwy ing the tinanci;Wy mp.oflslble party person to conduct the land -di+durbi ng :actvity o n
th-0 property.
rRoncr NAmE: OFF 5215 llA'I'k:: l lf1 ml
:1<DDRI1?1iS (W PROJEACT: 64Ap L1osAm C uFt
LA-H TU DIFJ ON GI TUDE DR PROPERTY AT SITE ENL TRANCE. 3:5_ 71-79 229
TOTAL DLSTLlRSED ACRES oTSQ ARE FEET: 1 ;5.taW)F
PUREUS'E OF ACTYVIT V. nz r-
FKE AMOUNT SU EMITTED:
LAN IX) Nr R () OF R FfORD (Hltach page ��.list additional �wnea s�
Plr ; - pruvidQ a wmpluto h5f of partnm' MR agiag members and regjsterad a enm if the resi onq isle e-n b tv or
land crwwr is a grc}up of individuals -corporate organization or entity.
Narnc: Triple A Hk)FneL3
phone:
Address, PO 80x 1117 T —Mail: laura tdpleahomes.org
I-folfy 5prfr'igs, ftiLC 27540 9i-7�� .. . _
isaMR14 0
Name:
Address=
Y RESPONS111 L.:, Pry R7'Y iE tl p OrII_r if di tRient f vm 13 y"y ow=)
phone --
NORTH CAROLIN A AGENT {applicable only if own-er or fi nand ally reWI Sibie "rtv jQeK 11t �1-0
North Carol in
Name: PhD=
ENGJNFF.RL$URVE;f=C' R
C0jnP NaM: Rimkl Wl Land SerwkARs. R l C
Addr&gs: 1917 Evans PA
Cary, NC 27513
Contact Perwu: I]4an Rhadm
L'hone: �1�978-9�yt}
1�-f : Sltswrm9r1s-rR .LxKu
F�XAsi I:
S�naturG
EROSION CONTROL
13'-L�rson to contact should crosio n & iorAi rr tnt
cnnkmi issues arise during Iand..dioUrbtogaC2jvity:
C,untoct p n: Clavid Uail
mpEury Name:
Phone` '919-Z70.7938
FWail: 0uv1Q1t 1rrPF6 ti13mQrj":g
Page2of3

�'��►�rr-al.� � �c�in�rr3r
Sail HTywilon and 4odimenta ion Control
w tt �c •r ri t- n �c tt �. � r,i n
Fi.aancfal Responsibility./O 'ncrsliip Form
PLEASE READ UiL FOLLOWING INFORM-eM
I1 This sccLbm m w c be �,igncd in Lb presence. oF a Narary
:2] All Land-Distnrbiag permits uc valid far up to ? ycam from the date of issuanog-- if cko mmmca wa=t die permit may be
eAU3i Leal fur (1) YI:Ar pCr Llx ctmmLI&3Mx of Ilk: Chalimin C:uuniy .rumiLlrl ;arld ''lcdi rileri[8ni V C oiruial Ordiriartee- I. Jim wriLHM
m uz4-- the Land-DisLimbimg permit may be rryoked I43r failure Lo a_mrpiy with Lhe Ordimme, Athe }rand is mmked, all. usher
pcmeim and appr"s arc withheld mul the pwputy is owc again in {omnplisircc -iLh C'harhnm C4anrty repulaioos_ Also_upam
wrirmel noTim *civil pwalry (fine) can be i rtL[.igared againse ik prcpeny owner andAw additional finaneiaily regpcnAFble parry (if any)
Ikv %iQlpkiom ofIhc (.lialham (,Vwnly;SrmI I-mNitm antE dinwnjRlign Cvnl3-4i[ f W'krmmor_ TWN JXnal3y M Mp Ln 11,WMI.00 rrer vinblinn
per day and is ssscsscd dEdly fcr cvM day dac prop:rLy is in %dolatioEL ]nCC� with X faM4 dag an retina 4.M ecsult in a civil
PtVA13y wift,ul ;+7ilier3 FlOi=-
3j The informarion pmvidcd nn dhis farm is mnre. and career m life hest of try+ lmawledc and baLief and -was prmided by me while
Ll Ldu Ually
4) T -i Win mm be Riga by the proXcLy owner if an i rrdiv idual_ if owned by a -comps" oT corporadoo_ this fb m rnnst ba Maned
by an 4ofticcr, dirwtm, pare r_ atbmey-im-MM m ANT gym with authority Lo execute ins�nts ki-rr I hp-, ccHrjx7mHkm jnd
m-wrrgmnkKt by a-vorigAkne IisL or al I Pmtnnem, nm navkqg immdm--m mid n_ElsacrM 2,yum1 -of IM cmlpiurj• kw w F aLiom
OWNER OF'PR(
Namc and 'rifle: Da e� Mors _ Pres 4nt _
(=ompaTky (if appl icak�l }_ T]l GAM
SignattLa
ADD1110 NAL FINANC3AL Y RUMONSMLE PARTY (if any):
r-4unre and TiLL--
Company_
NOK M CAROUNA AGENT (12ny):
fv m e. and'IiLlr:
t 'wnpaiay; .. - — -
SigtlaLlure:
( Laura Peters , a Na aey 1NrWic of WakL' C 43unty ire Lhe *;fate
of NWh rolina d, hereby IIM ry Iirrrt Darr Morse ,mL4
.Mppew-c3d bcfgrq rni-_ thix &7 and uncter auth aoknoxwl nd i mmEng L13m en formation akvwc and +wl-rdSvd tbaitbx,
atQW f4XM W S "CCL tad by him ter her.
WilnexS MV hadd aidCoffiCial seal. This ih tdety 4Yf'2U .
Nntmly Public
Mw rymrmNm rMT-
ex � 4 � i .Bit T+; cxii
08LI-C