NCC221089_FRO Submitted_20220321

CHATHAM COUNTY
N O R T H C A R O L I N A
Soil Erosion and Sedimentation Control
Permit Application
Please complete both pages of this form and return to:
Physical Address Mailing Address
80 East St. PO Box 548
Pittsboro, NC 27312 Pittsboro, NC 27312
Phone: [phone]
For Office Use:
Please check one of the boxes below for the permit that you wish to apply for:
❑✓ Land -Disturbing Permit: This permit is required for the following activities: (1) all new commercial, land
clearing/development, and non-residential projects greater than 20,000-ft2 and construction of all new residential dwellings
greater than 25,000-ft2 of uncovered or disturbed land
a. The following items are required to obtain this permit
i. Two copies of an erosion control plan which was completed and sealed by a professional land surveyor, professional
engineer, or registered landscape architect. This plan must meet the criteria provided on the Chatham County SESC
Plan Review Checklist and must include all disturbance and clearing for the project including driveways, yards, and
septic systems for residential projects.
ii. A permit fee of $250/acre of disturbance and a plan review fee for $250/acre of disturbance. These are rounded up
to the next whole acre. Example 1 acre or less is $500, 1.1-2 acres is $1,000, 2.1-3 is $1,500.
❑ Multi -Lot Residential: This permit is required for all multiple lot construction in the same subdivision by the same builder that
cumulatively disturbs greater than 25,000-ft2. All submittal requirements are the same as the Land -Disturbing Permit listed
above.
❑ Residential Lot Permit: This permit is required for all disturbance related to home building activities that do not exceed 25,000-
ft2 of disturbance. This disturbance must include driveways, yards, and septic system clearing. The following required submittals
must be submitted to Central Permitting when you apply for your Building Permit.
a. The following items are required to obtain this permit
i. A plot plan showing clearing boundaries and approximate location of the areas listed above must be included. This
plot plan is not required to be completed by a surveyor or engineer.
ii. A permit fee of $100 must be paid to Central Permitting when you apply for your building permit.
Should you have any questions regarding the above permits or required submittals please contact:
Land Development/Commercial Projects
Morgan DeWit, PE
Senior Watershed Specialist
919-542-8268
[e-mail]
Residential Lot Permits
Robyn Wharton
Watershed Specialist
919-545-8344
robyn.wharton @ chathamnc.org
Residential/Multi-Lot Residential Projects
Drew Blake
Watershed Specialist
919-545-8394
[e-mail]
Page 1 of 3

C14AX14AM CC) L1rI TTX
NORTF-F +CARr[]r F..FNA
Soil Erosion and Sedimentation Control
Permit Application
PROJECT NAME: Governors Club - Lot 664
LOCATION OF PROJECT: 23900 Cherry Chapel Hill, NC 27517
PARCEL #• 70222
TUI'AL DISTURBED ACRES or SQUARE FEET: .551 Acres
PURPOSE OF ACTIVITY• New single family construction
FEE AMOUNT SUBMITTED:
($250/acre plan review fee, $250/acre land disturbing permit fee)
DATE: 12/14/2021
LANDOWNER(S) OF RECORD (attach page to list additional owners)
Name: Jason Dell Phone: [phone]
Address: 60148 Davie E-Mail: [e-mail]
Chapel Hill, NC 27517 Signature:
FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner)
Name: Phone:
Address: E-Mail:
Signature:
NORTH CAROLINA AGENT (applicable only if owner or financially responsible party does not reside in
North Carolina)
Name: Phone:
Address: E-Mail:
ENGINEER/SURVEYOR
Company Name: Philip Post Engineering
Address: PO Box 4912
Chapel Hill, NC 27515
Contact Person: Phil Post
9198187562
Signature:
EROSION CONTROL
Person to contact should erosion & sediment
control issues arise during land -disturbing activity:
Contact Person: Ted Cieslik
Company Name: BOLD Construction
919 929 6288
E-Mail: Phil [e-mail] E-Mail: [e-mail]
Page 2 of 3

--,'1
cii -Axi cjpq- -y Soil Erosion and Sedimentatio
n Control
N 4 RTI-i CA RO LE NA
Financial Responsibility/Ownership Form
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 (1) year per the conditions of the Chatham County Soil Erosion and Sedimentation Control Ordinance. Uponwritten
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.
OWNER OF PROPERTY:
Name and Title: Jason Dell, Owner
Company (if applicable):
Signature: /
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY (if any):
Name and Title:
Company:
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature
Afshin Hosseinpour
North Carolina
County in the state
do hereby certify that Jason Dell personally
a Notary Public of Orange
appeared before me this day and under oath acknowledged reading the information above and acknowledged that the
above form as xecuted by him or her.
Witness MAan and official seal, this the 14th day of December , 20 21.
Notary Public
My commission expires 4/2/22
AFSHIN HOSSEINPOUR
�t Notary Public, North Carolina
Orange County
My ComMALi xpires
April 02, 2022
Page 3 of 3