NCC223258_FRO Submitted (7)_20220916

M ".Pr Yi !' h R 51 4 t N A
Lan d-Disturbin n
Permit Application
fleas virnplew both pages of this form and return t-o
Physical Address Maifirtg Address
SCM East 5t, PCl Box S-4S
Pi LWxmro, NC 273 12 P1 L&boro, NC 21n12
Phone: [phone]
ror C}icfi C Jse=
P7m,�c see $EIRM 171'ING FWW C.11,-tRT tc} dewrmine whiuli perm it and plan req u ircmt�nt�; app Iv to
your pm.jw and then chcck ontr of the boxzs below
0 1,xnd-DistAr>ing Permit, The fol]aWM9 LLems ar-c ri:y+a i r5ed to obwn this Permit: complctW
application, plans, and fccs. 1.and-LX5KFFb1np, Perinit appli rations ®wit include all parcel slots (in
-one appl Km ion with the tt}1a] amount ra f disturbanw frw al I parmLllmL All clearing aA dii"r0.mnce
must be i rrclu&-d wlin i--alC:ulaliag dist•urbcd area.
Fne Requiremwt-v _
Parm,i L Fee: M(Ydiswrbed acm
Ulan R-uvi w Fec; S2Wd-LAurbcd Herr.
I-ees are mended up to tW next whole itcrt�.
BKam le= 1 aac or less is $500, l _01-2 awvi is $1,000, and 2-01-3 is $1,500-
Plan Requ ircwrnM,
De�'_ subirEit (1) GWy of art 4-,r[k4ion control p[an complcl0 & snied by a professional kind
-$ur+reyor, pmfc�icmal engin=, cvr rq.istered I and-*c-�pe srcbit"t. This plan m ust uneei the Cnic- +a of -the
Chatham County Erosion rntml P Ian Ruvic w Checklist anal unclude all applicab le oDns ruclitm details.
'ffiaw rxm be f) and an the Chatham CA)urity %V a# r lmmj Protection wc:hsite- on tll. Fnvs m C mtrol
'his plan must satisfy. Al local, stag and Cederal rnirrim urn plan naquirernertts, n
Ggncrnl Flan: w"it {jj copy Of Bite plan along with the Chatham Counly Residential Gvntzal P Ian- 51tc
plan is not required to W complct-cd by a design profcsslonal- The RQ�id,efldal GCMral Plan can be f6und
on the (%, Whani Coun Ly Watershed Protection webmto ot, the [residential Construction wehpagc. Indwatr,
lot dram tatoern s on sheet l of the Re%Aential Gwen l Plan.
© l es len tial LM Permit- The follr,win:g items afe r quir tAT c,htai a this permit: wmpleled
appiication, silt plan, and fcc, FADE 3 "FINANCIAL, RESp - STj3TLI'I'Yf0WN1-RS1 LLL' F RTtirl„
not required. � . -
Fee Requirements: plan RequircmmLs:
100 flat fee Siw Plan showing property bmindafics. The site plan m-quired by the
FJnvij�errtal licahh ox Ctvtra] PcrrniUlan L?e ardncn� i suff'ici nt_ _
ALL C.IlrCKs MA[3F.YAVA131,1i TO C1 ,i,-MIA-M {.,OLtNT!'
Page Iof3

Land -Disturbing
F-M-1734A CFUN-<"1 Perm it Application
M -So M F •• S• A a o L I N A
*"Thiz mx.Wug axad street :address of die priritip2l PIACC Of I aMiUVSS for the personiex&Ey 15handall- rcgIro-nsible :1j11
the land owne(s) must A JP-()- box is NOT accept2 ble as an a&rtz y.
^'' If the finaaelail}• r j)1Dnsi M-e pcmua'pn rl* is ditl`ereaf from the current land awner, :en :3 �reemc nt .4gned by both
Tytirtiek m uxJ bl+ p 7 :3 I IoWi rig th-e flilxncially resFo-nsible p M perNon In L undue[ the Ian d-disi o rW(L9 a1zt3vity on
tlke property.
DATE: 619;22
A r1DRESS OF PROJECT, 1032 God revs VI , Pit !%b , NG 2nl2
LATITIJDE. 1.OINGTT1L DE OF PROPE RT V AT SITE ENTRANCE' 35•7-891-79-239
PAID 1. #( C M2504
•I TAL DISTU RUED ACRES or 9QUARE FELT: � 0.38 acres
pl,Rpo SE ()FAl`=TIV[TV, new 5FD
FY K AMOUNT Sl ]BM I'I-I-Elk.
*$ LAN WWIN47f RED 1'rT� att}ich a e t� li ��iii{�n�xL ou'ncrs
Ple€ provide a �xwrnplete i i st of part nem nianaiging r cwbeN and rcgislaW ageniM i fthe r-uponsible entity of
land o ncr iq a gnmp of in-div idual� corporate orrtimlion or entity.
Name- Triple A HornCs Plwllc- 4 12- r}t -
AdcirM-s,: PO 1117 E-Mail- lau pte +5,.40 -
Nolly Springri, NC 50* sigft=M' �. !
Name; _ --
AddTess'
NgRTi U:�
Ntwrth Carolina)
mama
Address:
b le only if difi-trent 1�m proyenY Qwrw
Phone-
i!N A AG f NT (appikWc residFc in
T-NGLNL E RiSl TRVE,YO
197 E vwB Rd
C-niv. NC 27513
C,mL,iCEPerson- D n Rhad$s
p}„=, 91!L-M- 310
Fbooe;
E-bait-
Situte;
"O(JON 1='OIVTR��.
PerSOM to cnn Jae# should Crosion & rce d wen t
"ntrod iasucs aria: slu riri%t Iand-disturbin k, Zvl
Cor,, t 1'erson: Sadd Dail
�'cmpany N=: Triple A Horner
Phaoc- 919-27D-11 $
�Ikis„ I • davidr.�trlplc�horxg
Pag�2of3

Soil Erosion and Sedinlev tenon Control
r� �► n , •rry Financial RespoTtsibility/own r rahip Form
Nal' kEQUIRED To fly_ C OMP ETFI)1• OR R&SMEA M 1. 1171' PERMUS.
PLEASE FEAR TI I H i OLLO INQ IN E'ORNIATIQ, _
1 } 'Phis %x-LIon must be sipitd ;n LIx prcS�a= 48 NMLF
2) All Lmd-I rhin9 perrrrits � -�licI fCrr up tv (2) }ears tMrn Lk of iSslL5mn=- If ccirct�YF7 UMOM WarnW3T finis p$ro7it May be
hg�r.�
exLended for (2) n per d i c candid D13s of G C:Iiadhrsm CbUnty Soil l:rcx WML and Saiimewaticm Ourivcd Of-dLuanov- 4.Twn wE LIAL
TKtiQe, Lhr Tend-DisturbbW 'pWMIL Irt y bO FCv cd Cur fziilun} to axnpty witb Ow o,rdLnuwr. if the permiz is rcuoksxd, all oth►ir
pornmilx mvL approve,als arc withhelcL urail the pwpo t)r is once alpin i n cawplhmztO v.iEh C'haMarn Courtly myulmions_ Also, l�M
wrirtcn ootVc� x t;viL p na]ty [�nej he ;rlstig�G[�d agein�l 1 gym, + + rr �rer amdf �rldiL;,�ns] finewinll±+ Tcq;m N c patty [if an}r)
f w vito-lal.lodU oftbe C'halfnam ICUurtty Saul Ucm' m and Sj3dilnQOMdon C onLml Ord fm=. Fhis rw d1LY is up to $50DO,00 per viablilan
per day and U a.n*vzd daLly kT tvery (Ly the Pers
rty Es un xivladt,. lrutcrttning m�� wilh 4,r h=Lpering as xLiork caaL result m 8 evil
perm,LY wilhqut writreaL 110tit; e,
3) 7lic intarawiun pR,+•oiled nn this farm is Roue and axrw tG the beA of my knawiedpe a� Me rf errd waS PTUvWLA L�y Inc while
undcr4-wth_
4) This form must be gkgnerl by the propv~rt±' c�rwrn ; f a�� or,dr5+i�ue7_ I f cptvncT] by a a�anpa cr ci ir]}i}t3tJiln_ this form rnu�t he sigl7cd
by an ufJ'%4M. director, paEier. WRW*ey-iWf3CTL. cr other FK:ffvmi with autim?,ity 4, cxoune ju5tnamemas for LIV Oxporntlan ;urcl
Scca parried by a oompLett LLqfall partners_ mnnagang TmM5LxzS and rqg�-rred agUULs of ibe {gmpany err wrporai"-
Namc wkd TirJe~ DLBn Eufp� President
Corr pmy (if applitzb l- Tti A °
�i�rrature- .
ADDMONAL 1•'I AN ALLY R> SPONTSMU PARTY (ifxny)-,
Name and Title-
S16ma[um: -
NORTH CAROLI N A ACTS I 1 (if:2 0Y)'
!*lame
CA,rrrpany;
4ieiLLre=
*********************q-:§*********T�*zJ;******�*:********* ******
11 �,Lf - _.a N{firy PuF0-3c of WT CourLty to OIC
of M*O C+ra -do perchy Curti ry that Ale per+wm LLy
appeADDd L' ryre nw (his day and under wLh ackn 'Lodged rrAd.ing the Lnt&rriaLi m above and aeknowledged thatYhe
aht,w rmm ww cxcruLvd by b i m nr her_
Wjtn�7 my IlarLd anal of vial peal, this file. Lt day of t
Z)&�-
N-olury Nblis
MY runLmis5 IOn exvmL. L -T�
,0TARJ,
(��JA ,) er L I rr t
f+rl�t
Page 3 Df.3