NCC241421_FRO Submitted_20240508

Applications may be submitted online:
https://chathamcountync.viewpointcloud.com/categories/1082
ram~- Land-Disturbing
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N f] RPermit Application
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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:
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) copy of an erosion control plan completed& sealed by a professional land
surveyor,professional engineer, or registered landscape architect. This plan must meet the criteria of the
Chatham County Erosion Control Plan Review Checklist and include all applicable construction details.
These can be found on the Chatham County Watershed Protection website, on the Erosion Control
webpage. This plan must satisfy all local, state, and federal minimum plan requirements.
General Plan: submit(1) copy of site plan showing proposed disturbance limits along with the Chatham
County Residential General Plan. Site plan is not required to be completed by a design professional. The
Residential General Plan can be found on the Chatham County Watershed Protection website,
Residential Land-Disturbing Permit webpage. Complete table on sheet 1 of Residential General Plan.
❑ Residential Lot Permit. The following items are required to obtain this permit: completed
application, site plan, and fee. Page 3 "Financial Responsibility/Ownership Form"not required.
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 I ATL-I A M C I IG M1 Permit Application
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**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 to conduct the land-disturbing activity on the
property.
PROJECT NAME: Chatham Park South PS I and 2&Associated Force Main DATE: 2/14/2024
ADDRESS OF PROJECT: 569 Moncure Pittsboro Rd
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.7005/79.1676
PARCEL#(S): 7461,7462
TOTAL DISTURBED ACRES or SQUARE FEET: 9.25 acres
PURPOSE OF ACTIVITY: Sanitary Sewer Force Main and Two Pump Stations
FEE AMOUNT SUBMITTED: N/A RIVER BASIN: CAPE FEAR
*Fee of$4,500 paid with original submittal dated June 2022
**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: (see attached list) Phone:
Address: E-Mail:
Signature:
**FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner)
Name: Chatham Park Investors LLC Phone: [phone]
Address: 105 Weston Estates Way E-Mail: [e-mail]
Cary, NC 27513 Signature: R
NORTH CAROLINA AGENT (applicable only if owner or financially responsible party does not reside in
North Carolina)
Name: Phone:
Address: E-Mail:
Signature:
ENGINEER/SURVEYOR EROSION CONTROL
Company Name: McKim&Creed Person to contact should erosion &sediment
Address: 4300 Edwards Mill Road,Suite 200 control issues arise during land-disturbing activity:
Raleigh,NC 27612 Contact Person: Robin Rose
Contact Person: Diandra Hyman Company Name: Chatham Park Investors LLC
Phone: [phone] Phone: [phone]
E Mail: [e-mail] E-Mail: [e-mail]
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270 consecutive
Summer 2024
ANTICIPATED START DATE: ANTICPATED END DATE:calendar days

Soil Erosion and Sedimentation Control
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N K L Financial Responsibility/Ownership Form
[1 1; 1 11 4 A 1a 4 1: I N. h
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.
5) This form must also be signed by the financially responsible party and NC agent(if applicable). Same provisions of#4 above apply.
OWNER OF PROPERTY:
Name and Title: (see attached Landowners of Record list)
Company(if applicable):
Signature:
FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner):
Name and Title: Robin Rose,VP Land Acquisitions&Construction
Company: Chatham Park Investors LLC
Signature: ..�
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
************************************* =****************************
1, M." I)., Mu,- ,' ,a Notary Public of UJ CL County in the state
of n1o1^1.1i ec,ro HA w do hereby certify that R ;r‘ 12. Rose_ personally
appeared before me this day and under oath acknowledged reading the information above and acknowledged that the
above form was executed by him or her.
Witness my hand and official seal, this the 141'4\ day of Fe.bru {t,'��i,,,,rr� , 20a
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Notary Public = Notary Public
Lee County My commission expires q-o9-q-a0a� = (S€AL)
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