NCC241609_FRO Submitted_20240531

Applications may be submitted online:
https://chathamcountync.viewpointcloud.com/categories/1082
Land-Disturbing
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Permit 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.
0 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
'''N' 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: Goldston Carbonton Road Waterline Extension DATE: 1/11ZT
ADDRESS OF PROJECT: Along Goldston Carbonton Road,from Roberts Chapel Rd.to a Point 4,999'South
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.584896/-79.331634
PARCEL#(S): NCDOT Right of Way
TOTAL DISTURBED ACRES or SQUARE FEET: 2.3451 acres
PURPOSE OF ACTIVITY: Replace existing 2"galvanized water main with 6"water main
FEE AMOUNT SUBMITTED: $1,500 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: NCDOT Phone:
Address: E-Mail:
Signature:
**FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner)
Name: Goldston Gulf Sanitary District Phone: :[phone]
Address: 14480 US 421, Goldston, NC 27252 E-Mail: g p@emb- gm�il. om�
Signature:
NORTH CAROLINA AGENT (applicable only if eitherfwner or ancially responsible party does not
reside in North Carolina)
Name: Phone:
Address: E-Mail:
Signature:
ENGINEER/SURVEYOR EROSION CONTROL
Company Name: Hilliard Engineering, PLLC Person to contact should erosion &sediment
Address: 3417 Winterwind Circle control issues arise during land-disturbing activity:
Sanford, NC 27330 Contact Person: Joseph Ricky Beal
Contact Person: Jarrod E. Hilliard, PE, CFM Company Name: Goldston Gulf Sanitary District
Phone:[phone] Phone: [phone]
E-Mail: [e-mail] E-Mail: [e-mail]
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ANTICIPATED START DATE: May 15, 2024 ANTICPATED END DATE: July 1, 2024

Soil Erosion and Sedimentation Control
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4Q ($ W , " , ft f* f 4 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:
Company (if applicable): NCDOT
Signature:
FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner):
Name an Title: Joseph Ricky Beal, Board Ch 'rman
Company: stop If ary Dis ict
Signature:
NORTH NT (if any):
Name and Title:
Company:
Signature:
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appeared before me this day and under oath acknowledged readin the information abe and acknowledged thatthe
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