NCC223859_FRO Submitted_20221121

Land -Disturbing
Permit Application
**The mailing and street address of the principal place of business for the person/entity financially responsible and
the land owner(s) 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 person to conduct the land -disturbing activity on
the property.
PROJECT NAME:ko!5� Woe, DATE: -
ADDRESS OF PROJECT:
LATITUDE/LONGITUDE OF PROPERTY AT ,SITE ENTRANCE: .J5d, � I ���?�
PARCEL #(S):
TOTAL DISTURBED ACRES or SQUARE FEET:
PURPOSE OF ACTIVITY: Qefi,mo �
FEE AMOUNT SUBMITTED:
**LANDOWNERS 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 gr1<1
of individuals, corporate organization or entity.
Name: �7c4 Qff Phone: 3
Address: E-Mail: "605S b 1r, 0-
ji
isi 6 Signature:
**FINANCIALLY RESPONSIBLE PARTY (applicable only if different from ro ertowner
Name: Phone:
Address: E-Mail:
t Signature:
NORTH CAROLINA AGENT (applicable only if owner or financially responsible party does not reside in
North Carolina)
Name: Phone:
Address: E-Mail:
ENGINEER/SUR
Company Name:
Address: (Oq
Contact Person:
E-Mail:(i r Yll het �'b�G�•5 " l`r C�
Signature:
EAEROSION CONTROL
Person to contact should erosion & sediment
control issues arise.during land -disturbing activity:
Contact Person: _L# 1 IA&Vk&J t RA.S 5
Company Name: /�
Phone: 414 ZA �(I
E-Mail: ai r_03 Y 0-6- �$ �
Page 2 of 3

Soil Erosion and Sedimentation Control
H AXIA A M C "u N-ir r
t� H Financial Responsibility/Ownership Form
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 PROPS TY:�^�
Name and Title: 1('� P' CT
Company (if
r Signature:
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY (if any):
Name and Title:
Company:
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
I, ►\0_0 , a Notary Public of County in the state
of do hereby certify that Loe SCgrKyFe tJ �s - personally
appeared before me this day and Linder oath acknowledged reading the information above and acknowledged thatthe
above form was executed by him or her.
Witness my h nd and official seal, this the �� day of Dl�G+-4� , 20 Z ?rlrr„ry r,
/11pla
Notary Public _ My O
e0MMI IQ EXPIRES
My commission expires SE
• - U
L1G
1f/I i rf 14 1rs30%
Page 3 of 3