NCC243075_FRO Submitted_20241004

**The mmaillinng and stireet address of the plrnnelp jIlace of husitness for the person/entity financially responsible and
the land owner(s) umunst be provideal,A P.O.box is NOT acceptable as an address.
**If the Maaallena➢➢y responsible party is different from the current land owner,ann agreement signed by both parties
must be provided ..showing tine ffiunamcialily responsible party to conduct tine Ilasid-distarbiang activity on the property.
This agree emit is provided on page 3 of this application and must be completed in its entirety.
FRO JECT NAME- Ellis Project DATE: 819/2024
ADDRESS OF P I,OJECT: 1415 Old Lystra Road
LATIITIUIlDE/ILONGITUD E OFPI�OPERTSY AT SITE ENTRANCE: (35.8699796,-79.0545083)
PARCEL#(5)0 60691
TOTAL DIISTU I';I::Th ACRES or SQUARE FEET:T: .52
PURPOSE POSEE OF ACTIIVIITY: new home single family
FEE AMOUNT SUBMITTED: 100.00 RIVER I:,AS1N: CAPE FEAR
**LANDS UNER(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: Allison and Chad Ellis Phone: [phone]
Address: 505 Harkness Cir Allison Ellis<ellisfanatic
E-mail: @gmail.com>
Durham NC 27705 �/z—�---/
Signature: l�
**FINANCIALLY RESPONSIBLE PARTY(applicable only if different from property owner)
Name: same as above
Phone:
Address: E-Mail:
Signature:
NORTH CAROLINA AGENT(applicable only if either owner or financially responsible party does not
reside in North Carolina)
Name: N/A Phone:
Address: -
E-Mail:
Signature:
ENGINEER/SURVEYOR EROSION CONTROL
Company Name: Freehold Land Surveys Person to contact should erosion £ sediment
Address: 1777 Fordham Boulevard,Suite 104 in Chapel Hill
coatir®p iss•;es arise during land-disturbing activitya
Contact Person:
Contact Person: Dean
Company Name:
Phone:[phone]
Phone:
E-Mail: [e-mail]
E-Mail:
Page 2 of 3
8/1 9/0
ANTICIPATED START DATE: 2024 ANTICPATED END DATE:8/19/2025

.� - s©n IEi°osio 1 and Seilmentation Colilitrr©Il
('tl-lfAI'IF-n A MI (,..CDIIIIN Y Runde�p �v 5��t� q � ti(777q�rp�t
as as a 14 6 A h 43 8 a i .9 11'1d1unde Re.Slp®1i igii.biiJ ity/O VV tier s�� jp 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.
OWNE 12 OP PI'OPIERTY:
Name and Title: lVA f
Company(if applicable)•
Signature: 'A _ ?. � 44� �
IFINANCIALLIY IRESPONS I I3tLIE PA I'TY(applicable only if different from property owner):
Name and Title: above
Company:
Signature:
NORTH CAI',°LINA AGENT(if any):
Name and Title: o/a
Company:
Signature:
**********************skyKok****************************sue************
I, M a-�4ca dun�('6,� ,�� ti ,a Notary Public of 6 Th,,-Fans County in the state
of f, <(r )- ear,.�; V,rLs: do hereby certifythat N ati)nrQ 1c:� �,.,- '=.D A°
fl 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 `5 day of .L Rs w;, ,20-V .
ly
7 C—,-"P
Notary ,r bh
My co wF"ssion expires (L E; ,r c � ;4�. ._ (SEAL)
IUTARVA LIVINGSTON
Notary Public,North Carolina
Durham County
Page of My Commission Expires
g i Septernber 14,2027