NCC232901_FRO Submitted_20230927

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`s>a�n�tYl•and-INsturhl�' Permit �ppfeation
Please Include all required silnitures. For Uffatl:x
Physical Andress Mailing Address
SO East St PO Bois SO
PAtsbow.NC 27312 Pinsk**.NC 27112
Phone:(9191 S45-11344
Pkase see PERMITTING FLOW CHART to determnne wiu.h perrna,plan.and tee requtrcmcnts
apply to your prosvt and then check one of the boxes below.
2"Land-Disturbing Permit The fotlowuslp menu are required so obtain th.s Krum completed
appincatwn, plates deed, and foes All clearing and disturbance must be usclu ed when calculating
disturbed area
Foe Re+gwrements.
See attached PERMITTING FLOW CHART
Foe fees that are rounded up to the next whole acre.
. 1 acre or lets is SSOO,101.2 acres is S L000and 2.01.3 is S I,50O
r ,,Re .i rrrnenta: 1
Iksn Plan submit(I)copy of an erosion control plan completed A.imbed by a professnanal land
sun eyve.professional engineer.or registered landscape architect.nit plan must meet the:nuns of t'he
Chatham County Erosion Control Plan Roes..Checklist and include all applicable consuucunn decals
These can be found on the Chatham County Watershed Protection rcb ite-on the Erasion Control
webpage This plan must satisfy all local.state.and federal minunum plan requirements
ctiefal Plan:submit 411 copy of site plan showing proposed dutwt'anct limns along with the Chatham 1
Count!, Residential General Plan Sue plan is not required to be completed by a design professional. The
Residentul Genera!Plan can be found on the Chadians County Watershed Protection webstte.
Residential I and•thstuthtng Permit wcbcsgc-Complete table on sheet 1 of Rcudemsal General Plea
❑ Residential Lot Permit The following items ate required to obtain the. pcdmit :vmpks cd
application. site plat. and tee. Page 3 "Financial Responsibdit)Ownership Form"not required
Fee Requirements: Plan Regwremenes.
L__SI00 flat fee Sate Plan showing ptoperty�nds^es and used disturbance limits The»le
plan rcqusrcd by the Environmental Health Department can be used as a base
ALL CHFCKS MADE PAYABLE TO(*HATH 01(.0kNlY
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rc)urty I.ani1•I)islurhint
Permit ‘pplicatiun
� 1
••I he rrialint and street address of the principal place of business for the person entth flaancialh respt'nsibie sad
the land ossser's)must be prodded_ ,C P O.boa is NO I-acceptable as as address
••I f the financially responsible parts is different from the current land owner.as agreement signed ha both parties
must be prosided allotting the Unsocially responsible parts to conduct the land-disturbing Whits on rlte propert,.
This agreement is presided on page J of this application and must be completed in its entirety.
PROJECT N A AI F. 250 Map*SCAM*Lane - DATE:
ADORIAN OF'PROJECT: 250 MaOM SOrrpa land Bon Cask.MC 2747
LAT17I.DE LONGITUDE OF PROPERTY .S1 SI I E.ENTRANCE: 36143604.79,471065 W
PARCEL IS): 759213
TOTAL DI ST 1'R B E D ACRES..SQUARE FEET: 1 900 sc
PURPOSF OF ACTIVITY: Floe.*Cyw-snarXs
FEE AMOUNT SLBMIITTED: S1COO RIVER BASIN:C_AtlFEAR
••LANIX)WNER(S)OF RECORD(attach page to list addittonalowncn)
Please provide a complete list of partners,managing member and registered agents if the respotuibk enemy or
land owner a a group of individuals.corporate organuatims or entity
Name Aankle Cobbs phone. [phone]
Addreis 5130 OLD US 421 S E-Mail: a*yaY196SQlyd-ea"
Boar Creek NC 27207 Signature �[►f,_ __
••FlNAS'U\I.LY RESPONSJL3LEPARTI tapplicati:cunit it diMien'from psvperlvowner'
Name. Phone,
Address E•Mail.
Signature
NORTH CAROLINA Atit.NT iapplicabk PrtlY it either owner or financially res_pututblc jwty does not
reside in North C'amlinal
Name
Address. — E•Naik --
Stenaature
ENQINEERI URVEYO(; EROSION CON-IRO
Parson to contact should erosion& sediment
company Name MooOnl�eGipnwrq
Address 324<lbc sI SMtI61.Soli*1200 control Issues arisc duo Inc land�slurhing attrs.h
Contact Person _
Cooler*Person 'awn Patskoakl Company\arse _
per:919.732 1300 Phone
E-Mail: Mao^osimoolooresamakairsprmanng°0^ E-Mail --
Pogo 2 of 3
ANTICPATED END DATE
ANTICIPATED START DATE.

tl!.:N^'..1 t e ru£cjlr F Soil ro.ion and Sedimentation Control
Finantiel Responsibility/Ownership Form
NOT REQUIRED TO RE COtfPI.ETE1)FOR RESIDE.VTUL LOT PERMITS
Pi.E' KL.�D THE FOLLOWING INFORMATION
t,n,,•wises
gam be ivied a die
re,eae et.ASE ` ie)
2 t 1 ti.kris alma be artgd by Ile property emote d s atdh.M.l If armed by to coso..e)a empeel a.a►as lee awe be aped toy es allege.
durseur pi*saaogNyee►ad er siren r.e..os wan geatny W taeaar imoo nnu.x ter eorpegrw eel gtogogp.aed by a ogrglew b 41
tom esees ws sal regorged eke Aiwaomen
et oeratrq a cwpeww
1 Ton
y is tiny aid Por aged of q,lKe lle 1 feel pormagew eta 2 flow*qyh
it U Ow lgwllegoeen a.d liru'.Iy respos.rble pay age Mllireal tar ce aplogtee sad apes of M pips rld true a elocawaeew
sciagreisdpos ele Ysroewn oessesar a eel--ahem M i.raw---rg.poaub-party 10 ewdeelre w pepad t..bdlrw bNS a.a ory eras
leadvoeges Voce*of hod tinselled ee des appeaaaa
S I The golensumes provided es*a loge a grog gad Naga to as bat et my knomislp sal leant ell*so pwded by err%Ado woks cell
6)All tertd-Denattes mums as valid for up re(al yaws are re det of w.rrsoa.U ceritmMeire sarn=der part elm be eneMd Ie
12)yews pa Iitt d ewgg et the Chahar,Cele*Sal[warns gad Sed.sanurtaa Gard Ori nsee Lyre gone=srsce.a.Lora nee..bee
prang may be revoked for talus lo gawMy wOh de Ones ce It at part 1s mated el ease peters sal ap emas sins eattald mai
Ile props* is ow*spas w oempligrroe gods Casdres Caney reple.ue.. Also,soon..hen sows.a red me ly Mort cans be sasip god
soma due grpwty erenre sabot aldbesents1 haaac.4y r seolit party(if try i foe name===a Ile Maas Camay Sod Imes=ad r
S hmeeerow Csswnd Wdsen. Ma pawky n op p S 000It•pee oastrar per dry sod is mom==Ay he awry dog as=mgry n a*shwa
Igaafelrla oil a►aa.pasr g as erpecwgn us aswk e a earn prn.ky wtbed wnem neat=
OWNER OF PROPEtt
Name and Tale- -- —
Cann any lif 1
Signature:
I.IN.•"sC IALI.1. RESPONSIBLE PARTY(applicable onll if different from property oss net :
Saar and Tole.
Company. _
NORTH CAROLINA AGENT(if aa,):
Noun and Tisk
Compact) _
Signature _ - - - --
Ott0a0•.••.•.••..*.*a00go•.••••.0.0•••0�•••••••••••••0••••••••••••
VCI �r_t .a!iota() Public of _ County on the wee
I. C.T,1,� _perk.0 b
of_N+ CC.e1 d i heceb) certify that Za
appeared before me dui day and under oath ackncn tedged reading II• inforns:ic abo.:and aanow lniec l that the
above form was eucuted by horn or ha ,` uu(ap
�J v .�` �Tr 'a,
witness my hand off icu I.this the & day of • ,1.' yF
otary Public L
,0
iCO lr t,`,Il .My oommis» n ufrts —
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