NCC220091_FRO Submitted_20220111

f-IIANI ['� rl c r
Please Complete both pages of this for.
Physical Address Mailing
80 East St. PO Box
Pittsboro, NC 27312 Pittsbor
Phone: [phone]
Land -Disturbing
Permit Application
and return to:
NC 27312
For Office Use:
Please see PERMITTING .FLOW CHART to determine which permit and plan req; u'rements apply to
your project and then check one of the (boxes below:
i
:Land -Disturbing Permit. The following items are required to obtain this permit: completed
application, plans, and fees. Land7Disturbing Permit applications must ineI d all parcels/lots on
one application with the total amount of disturbance for all parcel/lots. All cl3 g and disturbance
must be included when calculating disturbed area.
Ell
quirements;
Fee: $250/disturbed acreeview Fee: $2501disturbed acree rounded up to the next whole acre.
le: 1 acre or less is $500, 1.01-2i acres is $1.000, and 2.01-3 is $1,500.
Plan Requirements:
DE1 n Plan: submit (1) copy of an erosion control plan completed & sealed by alpr fessional land
surveyor, professional engineer, or regiptered landscape architect. This plan must �{n et 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
web a e. This plan must satisfy all loc4l, state, and federal minimum plan re uiretn nts.
General Plan: submit (1) copy of site plan along with the Chatham County Resi en ial General Plan. Site
plan is not required to be completed by design professional The Residential Geher 1 Plan can be found
on the Chatham County Watershed Pro ection website on the Residential Constructi n webpage. Indicate
lot drains apattern(s) oil sheet I of the Pesidential General PIan.
❑ Residential Lot Permit. The following items are required to obtain thispen-nit: completed
application, site plan, and fee. PAGE 3 "FINANCIAL RE SPONS IBILITY/OERSHIP FORM"
not required.
Fee Requirements: Plan Re uireme ts:
$100 flat fee Site Plan showing property boundaries. The site plan requi d by the
1 Environmental Health or Central Permitting Departments is s fficient.
ALL CHECKS (MADE. PAYABLE TO CHATHAM COUNTY
Page 1 of 3

4 1 2A I' 1 1.r#.4t C:t it I-, t
Land -Disturbing
Permit Application
-The mailing and street address of the principal place of business for the personlen'ti
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,
parties must be provided allowing the financially responsible party person to condudt
the property.
financially responsible and
agreement signed by both
land -disturbing activity on
PROJECT NAME: Lewter Shop Rd Tract Pohd Drain DATE: 12/1/2021
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ADDRESS OF PROJECT: 45 Thompson Road
LATITUDE/LO_NGITUDE OF PROPERTY AT SITE ENTRANCE: 35.790517031961514, -78. 466068154974
PARCEL #(S): AKPAR 17811
TOTAL DISTURBED ACRES or SQUARE FEET: 2.99 acres
PURPOSE OF ACTIVITY: pond drainage
FEE A-VIOUNTSUBMITTED: $1,5 0
i
"LANDOWNER 'S OF RECORD att ch aae to list additianal owners i
Please provide a complete list of partner , managing members and registered agents i the responsible entity or
Iand owner is a group of individuals, co no
organization or entity.
Name- Ft. Mill Investments, LLC. Phone: 919.380A559
Address: 1500 Morrisville Carpenter Rd dayid merferr it � q
E-Mail:
Cary, NC 27519
Signature:
Narne:
Address:
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North Carolina
Name:
Address:
ENOINEER/SURVEYOR
Cotnpalay Name: withersRavenel
Address: 115 Mackeran Drive
Gary, NC 27511
Contact Person: Wesley Perry, PE
Phone: 919,469.3340 —
E-Mail: wperry@withersravenel,com
cable only if different frotn ro er
Phone:
E-Mail:
Signature:
caner or financially res onsible_pal
Phone:
E-!Flail:
Signature:
EROSION CONTROL
Person to contact should erns
control issues arise during land.
Contact Person: David Ferrell
Company Name: Ft- Mill Investment
Phone; 919.38D.0559
E-Mail; [e-mail]
Page 2 of 3
& sediment
urbing activity:

NOT REQUIRED
1) This section must be signed in the preser.
2) All Lund -Disturbing permits are valid fi
extended for (2) years per the conditions c
notice, the Land -Disturbing permit may b,
permits and approvals are withheld until t
written notice, a civil penalty (fine) can be i
for violations of the Chatham County Soil I
per day and is assessed daily for every day 1
penalty without written notice.
3) The information provided on this form is
under oath.
4) This form must be signed by the property
by an officer, director, partner, attorney-ir
accompanied by a complete list of all partnea
Erosion and Sedimentation Control
leial Responsibility/Ownership For
BL' COMPLETED FOR RESIDENTIAL LOf PERMITS.
e of a Notary
LIP to (2) years from the date of issuance. If circui
the Chatham County Soil Erosion and Sedimentati
revoked for failure to comply with the Ordinance.
property is once again in compliance with Chath
;tigated against the property owner and/or additional
❑lion and Sedimentation Control Ordinance. This pt
D property is in violation. Interfering with or hamper
and correct to the best of my knowledge and
nner if an individual. If owned by a company or
tct, or other person with authority to execute
managing members and registered agents of the
OWNER OF PROPERTY:
Name and Tit] avid Ferrell, Manager
Cotnpany �t ppl' a F iA estmen , LLC.
Signature: t
ADDITIONAL FINANCIALLY R SPONSIBLE PARTY (if any):
Name and Title:
Company:
Signature:
NORTH CAROLINA AGENT (if any).
Name and Title: I
Company:
Signature:
appeared before me this, day and under c
above fonn was executed by him or her.
Witness my hand and official seal, this t
Notary Public d
My commission expires '[ -
a Notary Public of ' YIn
hereby certify that�YJVJ61 rUVW
acknowledged reading the information above
of , 2014-.
stances warrant, the permit may be
I Control Ordinance. Upon written
If the permit is revoked, all other
n County regulations. Also, upon
nanciaily responsible parry (if any)
'Ity is up to $5000.00 per violation
b an inspection can result in a civil
and was provided by me while
in, this form must be signed
its for the corporation and
or corporation.
County in the state
acknowledged thatthe
s
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Page 3 of 3