NCC231883_FRO Submitted_20230619

Applications may be submitted online:
https://chathamcountync.viewpointcloud.com/categories/1082
Land-Disturbing
c I I I IC C C'l t NA Permit Application
N u R 1 H J A it t7 1. t N n
Please include all required signatures. 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:
XI 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.
Fee Requirements:
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 $1,500.
Plan Requirements:
Design Plan: submit(1)cop; 1 a.l land
surveyor,professional engin( PLAN CHATHAM iteria of the
Chatham County Erosion Co working together to preserve&progress ion details.
These can be found on the C' = )ntrol
webpage.This plan must sat]
General Plan: submit(1)col 7 �el)f �y�,L) .6C7- .L(`) ( ie Chatham
County Residential General f sional. The
Residential General Plan can q/c L ( 7 9 ay
Residential Land-Disturbing r n 7a1 Plan.
r
Sr1dC ec A�1 �-tv tLf.Ar1(�.�cX C.b1/1/‘
0 Residential Lot Permit completed
application, site plan, anc WWW.chathamnc.org/comprehensiveplan quired.
Fee Requirements: Plan Requirements:
$100 flat fee Site Plan showing property boundaries and proposed disturbance limits. The site
plan required by the Environmental Health Department can be used as a base.
ALL CHECKS MADE PAYABLE TO CHATHAM COUNTY
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Land-Disturbing
CI IATI IAM CcniN EY
, A {� 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 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 land-disturbing activity on the property.
This agreement is provided on page 3 of this application and must be completed in its entirety.
PROJECT NAME: Morgan Sw ,IVI si on- Pk a DATE: 6/ 1 I R 3
ADDRESS OF PROJECT: Off Intl Font Road
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE:
PARCEL#(S): VI T 8 3 And 1435 -
TOTAL DISTURBED ACRES or SQUARE FEET: q. ( ( acve s
PURPOSE OF ACTIVITY: Si 111(.. f j lq sub v i OYI (31. loll)
FEE AMOUNT SUBMITTED: 1 5,owt7 RIVER BASIN: CAPE FEAR
**LANDOWNER(S) 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: FUIICY- mom Qidyt , U.C, Phone: qlq ' i.(I 7- 0057
Address: $go' FasrPark br, Suak 301 E-Mail: 'andawln e kilo land du►•corn
gal elf NC 1V 11 Signature:
**FINANCIALLY RESPONSIBLE PARTY(applicable only if different om property owner)
Name: (SQn'll. Q S 0V0. 1 Phone:
Address: E-Mail:
Signature:
NORTH CAROLINA AGENT(applicable only if either owner or financially responsible party does not
reside in North Carolina)
Name: f(N/A Phone:
Address: E-Mail:
Signature:
ENGINEER/SURVEYOR II EROSION CONTROL
Company Name: WavVCh MI WNW / PE Person to contact should erosion &sediment
Address: tog Arn60 Wald Run control issues arise during land-disturbing activity:
C610 MI, NC, 2196 Contact Person: IY1 Ahdjxlon
Contact Person: WUYvtt M i4(1 CU Company Name: RAID' La.Ad t DtwGlOVIIM
Phone: gig-- 593 -Milo Phone: q lq- 4l 1. 0051
E-Mail: Warm1+C.n hcl(et @ 5rnai •con) E-Mail: jUndtrJah i7 ftottrtoad(AL vtorn
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ANTICIPATED START DATE: (p / (q / oR0a1 3 ANTICPATED END DATE: 6/I 9 /a 0 c 9

Soil Erosion and Sedimentation Control
lc:FiATI-IA/VI CC)UNTY
N K ^ H I INA 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)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.
3)This form must also be signed by the financially responsible party and NC agent(if applicable).Same provisions of#2 above apply.
4)If the landowner and financially responsible party are different,the completion and signing of this page shall serve as documentation
acknowledging the landowner consents to and authorizes the financially responsible party to undertake the proposed land-disturbing activity on the
landowner's tract(s)of land identified on this application.
5)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.
6)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$5000.00 per violation per day and is assessed daily for every day the property is in violation.
Interfering with or hampering an inspection can result in a civil penalty without written notice.
OWNER OF PROPERTY:
Name and Title: 3AIrit.s F. A►1dason Monk( / Manag vi
Company(if applicable): Ful k ' - M O M'9 Cth leafy. , L.G
Signature:
FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner):
Name and Title: (Sa#Lt 4! o)01)Ve-)
Company:
Signature:
NORTH CAROLINA GENT (if any):
Name and Title: ( N I A )
Company:
Signature:
******************************************************************
I, Luau(,11 a Att.Rts ,a Notary Public of WOkL County in the state
of Nalki$ Carol,U. do hereby certify that 'Tams F. APwIMson personally
appeared before me this day and under oath acknowledged reading the information above and acknowledged thatthe
above form was executed by him or her.
Witness my hand and official seal,this the $ day of TUYLt ,20 a3.
Kau0A- 15. 7VIOAA LAUREN B MATAS
Notary Public Law") b. a NOTARY PUBLIC
WAKE COUNTY, N.C.
My commission expires ' /i$/ac 24 My Co(rfdnl9gikin Expires 08-18-2024
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