NCC223258_FRO Submitted (3)_20220916

ICHArHA C-)-1-LN7Y
N C-A I N C A Ad -.FP • T+�
L and-Dis4u rb iaO
Permit Ap p I i ratio a
1']easc op fete both gages of this form and return ; ix �r i�ft=cc t 1 sr.
mt
f hysi I Address Mailing Address
R1 I?ast St, PC) Box 548
11ittsboTa, NC: 27312 PitL4x", NC. 27312
Phon ; (919) 545- 68
fleas gee P r RNE[TTING FLOW CI IAX1' to &ttrrrmirle whiQh Permit and plan reguirmanrnts app ly to
yc7ur project wW Then cbM& cwne of the b=x he10+ '
0 i.mid-Distu rhirtg Permit_ The folk)wing items � re�quir-Gd ro Uhtaln thl" irersttir ovrnl,leE.ed
appl ;anion, Plans, " fees_ Land-DisEurbing Pcnrn iC applicati{}ns must include all pa=I,-AtP1s on
one applica6i)n with the 'Mal amount Of diqurbm= hir € ll parcu la,ts_ Ai[ cicanng and disturbanb�
niust be included wherr calmlating disturbcd area.
f'c-r Fturrgmcnts!
Pcrc i[ Fee: $25({disturbcd acrr,
Plan Rpvicvw Uee: $25MIsturbod avre
F QsamMundW UP to the next vhcic acm'
k mpkc : l acre or is $500, 1.01-2 acres is $1,illy]
and 2.01-3 i -; $1,500,
Plan Requacments:
I)esiya Flau, subrn i L (I) cope of an cn)sion comrrcri plan compieted & 5ca1cJ by a profs ssic,ral land
surveyor, professional �girtEer, or rr i�te laadxape archi�cr�t_'I is plan mu C meet the critrria of the
C`.hatham Count,, Frame -on C.oMol Plan Review (."hL-,�klist and incl ude all appli��ihI con�-tru�iinn details.
Those can he fourrrJ an the Chalh:rrt County Wm rshed Proux:Cion wcbsil�, rm the E.ro:�i{m Control
vwc �_ This ]an m ust sari � I lama]_ state, ar�d federal m inimum Ian uirernents.
f eral Plate; suhm it f 1) copy of site plan 4on- With the C adukim ��unt,r Residential C;erEera l Ptah. bite
plan is ncrt rcquired to bye completed by a do f-ign f rofess-lun l_ The Rcsidtntial Gencral PCan care be Found
orti th& C.hadLam County aU:MI)ed 111)ot"Eicm websitc on the Residcotial C onstrugtian webpagc. 1r,dicate
loL dminage paitt�M(&) ce shart I of the Residential Gcmeral PEan_
21 Rfsiden#sal Lot Permit- The f-0110w1na items axe required 1' `hEain #his P''nnit: cam pleted
Ti ation, situ plan, and fw- PAC`rE 3 "FINANCIAL Rr 5 PGNSIS1I .I TY/OWNERS 11113 FORM"
rrot ireld
Fri R uin�rn-vnt6,; Plow R a in=menbi: _
1 tFD it l free its E'lar7 Z;h(3 IIng Pz'[kpCrtY h�ru AdC-s- `l hr, site plan rcqui red by #ho
L•'wArrmmeatal lleal#h kw {:en ral puuitt ng Uc-partrrr is is suf - iellt_
ALL CfIE(V; M ADE PAYABF E TU Cj IATHAM COUNTY
Page I of 3

�• Land -Disturbing
C> AWHA Permit Applicatiu rt
*"'-fhe mAiling end strcxA add ress of the princig.11 pl:3-ce of huNinuss for the persnnivali�' fman6:311 • rt-sponsitFle and
the Itind ownegs) m Qsl Ise provided. A KO[ box is \ i�•F acccp[able ors an address.
"If the Fmnoeiaify responsible pt!"or 'party is XjTctren t frmu the fprrc rl r land u-wn r, A n n:gr a ni ent sEfgfted by both
pxrtics m us# be prx'wided ANGwing to a fi res racially responsi ble pitrty person to couLluct the land-tiisturbing Actiirr* an
the propeAy.
PROJECT NAM}?: DR G15
DATE: IM22
A DDRESS Of PROD r-. 35 RQWwuvd Court _
LAT IT U DE.OLONGIT UOE OF PROPH.RIV AT SITE ENTRANCE: 35,.n21-79.226
PA6R(' EL #(5): 033M
TOTAL D[4TU REED ACRE. i ar SQUARE P ET: 18,E SF
ruRPONE OF ACYMTY-' nm 5Fa _
FEE AMOfIN_I' SL_BBU.'I'I'E9' _
* * 1-A4 N R7NT:R 4 OF R ' RD attach a ro Cis# additi rnal r, rs
11kase pn-vv ide a comFlaL. Fist of p , managing mcrnbc� and register apralt if din J Spc�nt;i Le entity �r
lanJ owner is a groin of individuals, N ofganivaiian of entity.
Name_ Triply A Hnmen Phone- 94EL51 �!-0991
A dr s: PQ Bcm 1117 ,-Mail- Iavr l rs_°�
Holy SWngs, NC 27544 S-tAatllre= —
**Fief ANC1l fi rn proycnY+Lytl,
Name: Phune;
Addnss- _ _� F ME il-
NO FLTH 4, AWLINA A ,F�'T (apol i cable �nl� i f � � ler rye f�r��n��' respo�ibl4 does not • ' i�L� i�]
North Carolina)
'_dame:
Address'.
E.-NCTIN .R i 1 RVUy R
Cumj?8 ray Names RG*W.r7iW Land 3aMc$s, PT -LC
AUKS&: 1 A 7 Evans R(J
CarY, NC 2751,' —
C.nntanL Person_ [dean Rhudes
Rhone: 919_1�7&4316
P'hunt:,-
-Mad:
SignatLuir.
CR0SI N C } N TRiDL
Person tfp wntact should crmion sad iment
eual of imoes arise +Iuriug I3nd-dislurbiTk9 :&etiiY tY'
,[act €fin- David Di::
I~A mpany Nana:-
Phcru�: 914-270-19
Page z -of a

CH�►� A P 3%P A
Soil F r ion and SedimentatlDll CnntrOl
ry ai R 7 W r, w x KF �. M 'Fixta ial Responsibill l ' nership Form
NOT RE UiBLED M BE CO f.?" O) FOR R1-..%w)R,N'IZ?iL 1,VT.PEBu '.
L4�TN i CN FQ
ATION'
1 � "L1hie S�Ct�On ,rail be �i Fn the prizl�, of a Vco-'lanr _
2) All L&ild-piMirrhiny, fxrmns are valid Foe up � (2) y From the d;We ref iseuen� If oinvnt z ti+MlTartL tbt pwm IL may be
adCad I 1143r (2) yem per the conditkm Lif ehc Cbadmm (-.L Lm[y 5631 Pm,x",n and Sa&mcnrwion CaTool i ]rdimanco. Upon ,YL-ri cn
nryiiw, the L.and•tli-oaf iryg pt cmuL irrav be rewkt;d for fklw-e lio ourizply with the Ordnrancc. Lf the permis is rewo} cd, all other
pcxsnitS and Spm�raLs wit}7held uruiL 1 PM}' 11 uncc again in r{,, ritril ianee with iti• lkt Iwn C4u F]kw r M u18ti On5. { L%u, P~'
wriklem notice a -Cjv-L pcitiahy (ine) c&n be instPocj nst tine prurerW r Tter �-c�a addtiumal li nancialf} r+ r�e.itrlc part} i any}
fLW vio-fefionx of Lhc Cbwffiam Ctmu,[f Soil V-1cm and SodiTm!nLalion CzMmL Ordinaxe. 11�s renat3r is up lu *15ik[ -00 per riialation
per &y anal is gssrxxeci daily far wry &Y tiro lrpny is in vLolartlon. 111twfcring i1h or baking m, iitispectiam ran result m a CiwiC
penalty uiihclia wriacn acAke.
3�'Llrc intom�ukiun prrwided an L�wS frrm is t ue quid-ckwrca to th%- Fx o€my knu►+lo�ig arrd b irf was v+id�xL by inc whip
uD r nuih"
4) This form Ir5ust be Signed by dsc FrCT&rly 43wner if am jndivr dv$]" if.DwnW by a conipemy -or awporadcHn, lrnix lbrm must be Ni-&;nLx.L
by an officer. diroactr, prtner, altOrney-l71- �+ � pram, with aathuriIv lit exomic IMS Lrtwwws fm the �,rporatium and
RCIEWnpaniei by a Curnpkin IisC of all T.Q,rmcr& a WWOng nk"Ubcrs and n=9's[cmj aV!!nLN L�F ncc cwpRa+ny or oorporautln.
OWNER OF PROPEKJCY:
Name and Title: !]ail 4-, Prey" rit
clyrnpauy (ifI e ; r�p s
ADDITIONAL r WANT= (ALLY RE SP l K Sl BLE PARTY (ifa n►):
Name and Titic-
Company,
Signaft":
N ORTH CAROLrINA AGF.N,r (ifauy):
Name =d T ft:
Campany ;
Signs :
�;a Nrrt&Ty Public of county in Lhe AMC
of` �} do hcmb�y c4rrifythat D�i,f 2✓a>: ?'
appnred bc`q= r= ibis da}and uLkav oath wknt)wledgod reading the informtion abcAcc and acknowlrdged thothe
above r4yrm h-w cx treed by him Dr her -
Wilts my hand and official seal, #big tt;ei7 day of 2-D
kz—
Nowy F'ubLzo
my UCKM nissiom expi res L
Fal3e3Cif 3
(-.5 KAL)