NCC223797_FRO Submitted_20221115

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ORANGE COUNTY PLANNING AND INSPECTIONS
EROSION CONTROL AND STORMWATER DIVISION
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NORI'H CAROLINA
1. Name of Project:
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APPLICATION
EROSION CONTROL PLAN
LAND DISTRUBING PERMIT (LDP)
STORMWATER MANAGEMENT PLAN (SMP)
131 W . Margaret Lane - Post Office Box 8181
Hillsborough, NC 27278
[phone]
https•//www oran e� coutitmc g_ov/13Q2lErosion-Control-Stormwater
8199 Mary Hall Road
2. Parcel Identification Number (PIN): 9899136538
3. Size of Tract:
4. Fees:
25.47 acres;
Erosion Control Plan Review
Required with Application
Land Disturbing Permit
Optional with Initial Application
Stormwater Management Plan Review
Orange County Planning Jurisdiction Only
Required with Application
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Planning Jurisdiction. Orange County
Area Disturbed: 1.5 acres � 5 � y p S • �r
$ 225
S 4s a
$ 300
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FOR OFFICE USE ONLY
Date Paid
Date Paid
Date Paid
5. Approximate Date Land Disturbance Will Begin:
October 2022
6. Landowner(s) of Record: (Use additional pages if necessary and attach to application)
Larry Jacobs Name
Name
4023 New Sharon Church Road
Street Address
Current Mailing Address
Hillsborough NC 27278
Cite State Zip
919-309-4350 n/a
Telephone Fax
gacobs@ jacobsglass.com
Email Address
Street Address
Current Mailing Address
city
Telephone
Email Address
Receipt #
Receipt #
Receipt ##
State
Fax
Zip
Page 1

Future Landowners (if applicable): (Use additional pages if necessary and attach to application)
Company / Organization
Contact
Street Address
Current Mailing Address
City State
Telephone
e-mail
Zip
Company / Organization
Contact
Street Address
Current Mailing Address
City
Telephone
e-mail
7. Person(s) or Firm(s) Financially Responsible for this Land Disturbing Activity:
Company / Organization:
Contact
Larry Jacobs
Street Address
4023 New Sharon Church Road
Current Mailing Address
Hillsborough
City
919-309-4350
Telephone
NC 27278
State Zip
Company / Organization:
Contact
Street Address
Current Mailing Address
State Zip
City State Zip
Telephone
IjacobsC�jacobsglass -com
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)
Name
Street Address
Current Mailing Address
City
Telephone
Email
State Zip
Page 2

10. Plans Prepared By:
Veteran Engineering Associates, Inc.
Name of Person or Firm
Po Box 1625
Mailing Address
Durham NC 27702
City State Zip
Thomas R. Kagarise, P.E., President
contact Person
[e-mail]
Email
[phone]
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.
Title or Authority
hereby certify that
Type or Print Name Legibly
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Date
a Notary Public of the County of UO—OJKI�
personally 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
Signature of Notary
SEAL _
Nor
SC/C
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121
My Commission
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