NCC233399_FRO Submitted_20231114

Applications may be submitted online:
' https://chathamcountync.viewpointcloud.com/categories/1082
Land-Disturbing
CI IATI 1 n,' CitAlINI Y t' Permit Application
Please include all required signatures. For Office Use:
Physical Address Mailing Address
80 East St. PO Box 548
Pittsboro, NC 27312 Pittsboro, NC 27312
Phone: [phone]
Please see PERMITTING FLOW CHART to determine which permit, plan, and fee requirements
apply to your project and then check one of the boxes below:
0 Land-Disturbing Permit. The following items are required to obtain this permit: completed
application, plans, deed, and fees. All clearing and disturbance must be included when calculating
disturbed area.
Fee Requirements:
See attached PERMITTING FLOW CHART
For fees that are rounded up to the next whole acre.
Example: 1 acre or less is $500, 1.01-2 acres is $1,000, and 2.01-3 is $1,500.
Plan Requirements:
Design Plan: submit (1) copy of an erosion control plan completed& sealed by a professional land
surveyor, professional engineer, or registered landscape architect. This plan must meet 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
webpage. This plan must satisfy all local, state, and federal minimum plan requirements.
General Plan: submit (1) copy of site plan showing proposed disturbance limits along with the Chatham
County Residential General Plan. Site plan is not required to be completed by a design professional. The
Residential General Plan can be found on the Chatham County Watershed Protection website,
Residential Land-Disturbing Permit webpage. Complete table on sheet 1 of Residential General Plan.
El Residential Lot Permit. The following items are required to obtain this permit: completed
application, site plan, and fee. Page 3 "Financial Responsibility/Ownership Form"not required.
Fee Requirements: Plan Requirements:
$100 flat fee Site Plan showing property boundaries and proposed disturbance limits. The site
plan required by the Environmental Health Department can be used as a base.
ALL CHECKS MADE PAYABLE TO CHATHAM COUNTY
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Land-Disturbing
c1 I1vrr la,> i ('c,uN-r Permit Application
**The mailing and street address of the principal place of business for the person/entity financially responsible and
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,an agreement signed by both
parties must be provided allowing the financially responsible party to conduct the land-disturbing activity on the
property.
PROJECT NAME: _ Chapel Ridge Lot 288 _ DATE: 11/1/2023
ADDRESS OF PROJECT: 87 Bob white
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.7905/-79.2128
PARCEL#(S): 82041
TOTAL DISTURBED ACRES or SQUARE FEET: .51 Acres
PURPOSE OF ACTIVITY: Build New Residential Home
FEE AMOUNT SUBMITTED: $100 RIVER BASIN: CAPE FEAR
**LANDOWNER(S) OF RECORD (attach page to list additional owners)
Please provide a complete list of partners, managing members and registered agents if the responsible entity or
land owner is a group of individuals, corporate organization or entity.
Name: Glenwood Homes LLC Phone: [phone]
Address: Pn Rnx 90427 Ralaigh NO 27F7s E-Mail: [e-mail]
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:
Signature:
ENGINEER/SURVEYOR EROSION CONTROL
Company Name: Residential Land Services PLLC Person to contact should erosion &sediment
Address: 1917 Evans Rd. Cary NC 27513 control issues arise during land-disturbing activity:
Contact Person: Chad Knat,ik
Contact Person: Dean Rhodes Company Name: Glenwood Homes
Phone: [phone] Phone: [phone]
E-Mail: dean@rls-nc com [e-mail]
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ANTICIPATED START DATE: 11/30/2023 ANTICPATED END DATE: 11/1/2024

Soil Erosion and Sedimentation Control
CHATI-IAM CC)UlNM'
NI [) II C ^ IS [1 I I Al ^ Financial Responsibility/Ownership Form
NOT REQUIRED TO BE COMPLETED FOR RESIDENTIAL LOT PERMITS.
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 (2) years per the conditions of the Chatham County Soil Erosion and Sedimentation Control Ordinance. Upon written
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.
5)This form must also be signed by the fmancially responsible party and NC agent(if applicable). Same provisions of#4 above apply.
OWNER OF PROPERTY:
Name and Title: Thomas Quackenbush Managing Member
Company (if applicab e): ood Homes LLC
Signature:
FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner):
Name and Title:
Company:
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
******************************************************************
'at Mew Ke.-tn f(OvSr_ , a Notary Public of 5Oh 3 fog County in the state
of Mf v (C. t do hereby certify that 1Ofri iS G 4,-5t personally
appeared before me this day and under oath acknowledged reading the information above and acknowledged thatthe
above form was executed by him or her.
Witness my hand and official seal,this the ri day of IAG1� •20 ,11I III/j
NotaryPublic o 140TARY m *
*Cianrrission Expires
My commission expires 10 — - 5 =( L.)10-5-2025
•• PUBLIC �V\
"s oN CoU 0
0/llt1W
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