NCC223705_FRO Submitted_20221031

OR N! E COUNTY
NORTH CAROLINA
ORANGE COUNTY PLANNING AND INSPECTIONS
EROSION CONTROL AND STORMWATER DIVISION
APPLICATION
EROSION CONTROL PLAN
LAND DISTRUBING PERMIT (LDP)
STORMWATER MANAGEMENT PLAN (SMP)
131 W. Margaret Lane - Post Office Box 8181
Hillsborough, NC 27278
[phone]
litti)s://www.oi,ati�eCOLIlItYlIC.Pov/ 1302/Erosion-Control-Stormwater
1. Name of Project: Rutkowski Residence
2. Parcel Identification Number (PIN): 9851122928 Planning Jurisdiction: County
3. Size of Tract: 12.1 acres; Area Disturbed: 7 acres
4. Fees:
Erosion Control Plan Review 1050
Required with Application $
Land Disturbing Permit
Optional with Initial Application $
Stormwater Management Plan Review
Orange County Planning Jurisdiction Only 500
Required with Application $
Total $ 1550
5. Approximate Date Land Disturbance Will Begin: 10/15/22
FOR OFFICE USE ONLY
Date Paid Receipt #
Date Paid Receipt #
Date Paid Receipt #
6. Landowner(s) of Record: (Use additional pages if necessary and attach to application)
Lauren Rutkowski Joel Rutkowski
Name
510 Boulder Point Drive
Street Address
510 Boulder Point Drive
Current Mailing Address
Chapel Hill NC 27516
City State Zip
914-345-2155
Telephone
[e-mail]
Email Address
Fax
Name
510 Boulder Point Drive
Street Address
510 Boulder Point Drive
Current Mailing Address
Chapel Hill NC 27516
City State Zip
914-345-2155
Telephone Fax
[e-mail]
Email Address
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Future Landowners (if applicable): (Use additional pages if necessary and attach to application)
Company / Organization Company / Organization
Contact
Contact
Street Address
Street Address
Current Mailing Address
Current Mailing Address
City State "Zip
City State Zip
Telephone
Telephone
e-mail
e-mail
7. Person(s) or Firm(s) Financially Responsible for this
Land Disturbing Activity:
Company / Organization:
Company / Organization:
Lauren Rutkowski
Joel Rutkowski
Contact
Contact
510 Boulder Point Drive
510 Boulder Point Drive
Street Address
Street Address
510 Boulder Point Drive
510 Boulder Point Drive
Current Mailing Address
Current Mailing Address
Chapel Hill NC 27516
Chapel Hill NC 27516
City State Zip
City State Zip
914-345-2155
914-345-2155
Telephone
Telephone
[e-mail]
[e-mail]
e-mail
e-mail
8. Registered Agent (if any) for the Person(s) or Firm(s) Financially Responsible:
(NOTE: a North Carolina agent is required if the applicant is not a
resident of North Carolina)
City State Zip
Name
Street Address
Telephone
Current Mailing Address
Email
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9. Pro'ect Description:
Project will include the construction of a single family residence with additional outbuildings, barn, and horse paddocks. As
we as the construction of supporting infrastructure such as access drive, septic field, private well, and geothermal wells.
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10. Plans Prepared By:
Civil Consultants, Inc
Name of Person or Firm
3708 Lyckan Parkway, Suite 201
Mailing Address
Durham
City
NC
State
William (Randy) Akin, PE
Contact Person
[e-mail]
Email
27707 919-490-1645
ttp
Telephone
11. Signature and Witness: the above information is true and correct to the best of my knowledge and belief and was
provided by me while under oath.
Signature of Financially Responsi e
OwN�R�
Title or Authority
6AIt-j eAf i2vTK0ijS
Type or Print Name Legibly V
f/it,/zZ
Date
I, kv tSfie- I a Notary Public of the County of�-
hereby certify that Lwve-g�L+kfw%,i Jt; e._I ku, ibpr,-.Jo'pally before me this day and under oath
acknowledged that this Application for Erosion Control Plan Approval, Stormwater Management Plan
Approval and Land Disturbing Permit / Statement of Ownership and Financial Responsibility
was executed by him or her.
Witness my hand and notarial seal, this Day of AUZjCA.-'-i- aU r'z
T -LL hJ N i5 V c )-vL k -e ✓ `30 ,a o Q y
Sig tore of Notary My Commission Expires
SEALCommonwealth of Pennsylvanla - Notary Seal
Kristie Beier, Notary Public
Wayne County
My commission expires November 30, 2024
Commission number 1273278
Member, Pennsylvania Association of Notaries
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