NCC243145_FRO Submitted_20241010

Land-Disturbing
CI'ATIIANI COUNTY
" It I • ^ it I P INA 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: The Conservancy- Internal Watermain&Access Road DATE: January 22, 2024
ADDRESS OF PROJECT: 397 Partian Road New Hill, NC
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.662388/-79.028915
PARCEL#(S): 5233, 5238, 5504, 5558, 5559, 5774, 5775, 5780, 60441, 62390,65274, 65275, 85343
TOTAL DISTURBED ACRES or SQUARE FEET: 13 Acres
PURPOSE OF ACTIVITY: Watermain Replacement
FEE AMOUNT SUBMITTED: 6,500.00 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: Chatham Land Group LLC(Marti Smith) Phone: [phone]
Address: 108 Dunedin Court E-Mail: [e-mail]
Cary, NC 27511 Signature:,,f t by
**FINANCIALLY RESPONSIBLE PARTY(applicable only if different from property owner)
Name: The Conservancy Real Estate Group, LLC Phone: [phone]
Address: 610 Hawks Ridge Court E-mail: and .ross@ evelopme t.com
Apex, NC 27539
Signature:
NORTH CAROLINA AGENT(applicable only if either owner or financially responsible party does not
reside in North Carolina)
Name: Phone:
Address: E-Mail:
Signature:
ENGINEER/SURVEYOR EROSION CONTROL
Company Name: CE Group, Inc. Person to contact should erosion &sediment
Address: 301 Glenwood Avenue, Suite 220 control issues arise during land-disturbing activity:
Raleigh, NC 27603 Contact Person: Bryant Montague
Contact Person: Mitch Craig, PE Company Name: Montague Development
Phone:[phone] ext 108 Phone: [phone]
E-Mail: [e-mail] b ant.monta ue monta uedevelo ment.corn
E-Mail: ry 9@ s p
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ANTICIPATED START DATE: 4/1/2024 ANTICPATED END DATE: 7/1/2024

Soil Erosion and Sedimentation Control
CHATI-IAM CC/LINTY
T
N n N'1 1i C.,AN.i I. I N,. 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: Marti Smith, Manager
Company(if 7p lie). ChathamLand Group, LLC
Signature:
FINANCIALLY RESPONSIBLE PARTY(applicable only if different from property owner):
Name and Title: Andre, '. - Man-:er
Company: The Co, ervancy Re:I s -te Group, LLC
Signature:
NORTH CAROLINA AGENT(if any):
Name and Title:
Company:
Signature:_
* {*/****************************************************************
I, }_ (vibe 7- 1— IAA 0 ,a Notary Public of \(\ja Q_, Countyin the state
of N,
(7•{ I do hereby certify that r fr-e J 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 � ay of ,20 ��,,,, 11°""'�o,�
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Notary Public I OTA `ctcw�
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My commission expiresL V. C2 �� (SEAL) •I
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