NCC230275_FRO Submitted_20230206

NS
O15F.RU1UN CON I'ItUL AND TORMA'I 1 RIDIVISlv,ECTJI,ON
APPLICATION
ORANGE COUNTY EROSION CONTROL PLAN
NORTH CAROLINA LAND DISTRUBING PERMIT (LDP)
STORMWATER MANAGEMENT PLAN (SMP)
131 W. Margaret lane . Post office Box 8181
Hillsborough, NC 27278
[phone]
htt :/ www.oran ecoun nc. ov/1302/Erosion- ontr l t rmwater
1 NameofProject: NC1-86 Leal
2. Parcel Identification Number (PIN): 9769492866
3. Size of Tract: 2.1
acres;
4. Fees:
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
Planning Jurisdiction:
Area Disturbed: 0.9 acres
$ 125.00
$ 300.00
$
Total $
5. Approximate Date Land Disturbance Will Begin: 3-1-23
Chapel Hill
FOR OFFICE USE ONLY
Date Paid 1
Date Paid
Date Paid .
Receipt #
Receipt # --
Receipt # 1-
6. Landowner(s) of Record: (Use additional pages if necessary and attach to application)
Jasmim Leal
Anderson Tegami
Name
Name
685 Dairyland Rd
685 Dairyland Rd
Street Address
Street Address
680 Bellflower Ave, Apt. 14
680 Bellflower Ave, Apt. 14
Current Mailing Address
Current Mailing Address
Sunnyvale CA 94086
Sunnyvale CA 94086
City State Zip
City State !ip
808-475-4818
808-475-4818
Telephone Fax
Telephone Fax
[e-mail]
[e-mail]
Email Address
Email Address

Future Landoj�,ne
rs (if applicable): (Use additional pages if necessary and attach to application)
Co
tttpa,y / Organization
Contact
Strltt -Add,,,,
Current Mailing Address
Ciry
Sta�� Zip
Telephone _
e-mail
Company / Organization
Contact
Street Address
Current Mailing Address
r�
Stat~Zip
City
Telephone
e-mail
7- Person(s) or Firm(s) Financially Responsible for this Land Disturbing Activity:
Company / Organization:
Jasmim Leal
Contact
685 Dairyland Rd., Chapel Hill, NC
Street Address
680 Bellflower Ave., Apt. 14
Current Mailing Address
Sunnyvale CA 94086
Cite
808-475-4818
Telephone
[e-mail]
e-mail
State Zip
Company / Organization:
Anderson Teaami
Contact
685 Dairyland Rd., Chapel Hill, NC
Street Address
680 Bellflower Ave., Apt. 14
Current Mailing Address
Sunnyvale CA 94086
Citv State Zip
808-475-4818
Telephone
[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)
James Rumley
Name
110 Horizon Drive, Raleigh, NC 276
Street Address
110 Horizon Drive, Suite 320
Current Mailing Address
Raleigh NC 27615
City State Zip
240-886-3229
Telephone
[e-mail]
>M

`�. Pro.ect Uescri Ilion:
New SFD, 5 BR, 4 112 Bath, Crawl space, rear deck, rear screened porch

10• Plans Pre ared By
rseslaentl I
Name of person orFirn a110 �erVICeS, inc.
1917 Evans Rd.
Mailing Address
Cary NC 27513
city
State Zip
Dean Rhodes
Contact Person
dean @ rls-nc.com
Email
919-378-9316
Telephone
11• signature and Witness: provided by me white undthe above information is true and correct to the best of my knowledge and belief and was
er oath.
Sip Jasmim Leal & Anderson Tegami
g re of F ancially Responsible Type or print Name Legibly
Owner/Financially re ponsible party
Title or Authority Date
I' �h beS a Notary Public of the County of �If> i� Uara
hereby certify thatAMa,-traati l a� TgSng i1 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 No
SEAL
RONA MAE ALBESA
COMM, ##2384220 z
to `- Notary Public • California o
-« Santa Clara County
M4 Comm. Ez fires Nov. 22, 2025
-D-.ceV6er 121X;l .
6 - -?? Z25
My Commission Expires
A nnra ry public or other officer completing this certificate
verL-es only the ldentl%of the Ind IV] dual who signed the
document to which th s certificate is attached, and no
j he truthfulness, accuracy, or validity of that document
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