NCC233811_FRO Submitted_20231228

Applications may be submitted online:
irip.:l:chathamcoungmc.vievbpointcloud.cornicategorres/1034
Land-Disturbing
etiAT !AA Cti)U' `IITl'
_ « ' ` ' 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 tee requirements
apply to your project and then check one of the boxes below:
Lip Land-Distnrbing 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 arc rounded up to the next whole acre.
Example: I acre or less is$500, 1.01-2 acres is$1,000,and 2.01-3 is $1,500.
•
Plan Requirements:
J)esirtn 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
wcbpage. 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 wcbsite,
Residential Land-Disturbing Permit wcbpage.Complete table on sheet I of Residential General Plan.
0 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 fcc Site Plan showing property boundaries and proposed disturbance limits. The site
plan required by the Environmental Health Department can be used as a bast.
ALL CHECKS MADE PAYABLE TO CHATHAM COLNTY
Page 1 of 3

Land-Disturbing
c'llA7-t1AM ('C>tt114 r1•
"' " I •a 4 a I. 1 + N Permit Application
**The mailing and street address of the principal place of business for the person/entity Cusaacially responsible and
the land owncrls) must be provkled. A P.O. box is NOT acceptable as as address.
**If the financially responsible party is different from the current hind owner,an agreement signed by both parties
must be provided allowing the financially responsible party to conduct the land-disturbing activity on the property.
This agreement is pros ided on page 3 of this application and must be completed In its entirety.
PROJECT NAME: LOT 7443 GoIEttracts CLUIS DATE: l2111202.3
ADDRESS OF PROJECT: 2,314 pN4I L C Q u 1, Mc- 275'
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.2'101o3, —ito35655
PARCEL 11(S): 000 31 22
TOTAL DISTURBED ACRES or SQUARE FEET: •2432 arc / 130wo 5 kir-
PURPOSE OF ACTIVITY: 61 S+tw tx-Fes,.i ttSiceiTi'tt. eiNlitrekkOnoi
FEE AMOUNT SUBMITTED: * I00. - RIVER BASIN: CAPE FEAR
ssLANDOWNER(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: H14 DAM , SKINK DM Phone: Ili 720 3572
Address: ISM hl4kkW hi*C Wet E-Mail: Ann.aarii4,*vine 4i.{-iook.can1/4
CAR-- i N` 27 514 Signature:____75701,141L1
**FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner)
Name: _ _ Phone: _
Address: _ E-Mail:
Signature:
NORTH CAROLINA AGENT(applicable only if either owner or financially responsible party does not
reside in North Carolina)
Name: Phone:
Address: E-Mail:
Signature:
ENGINEER/SURVEYOR EROSION CONTROL
Company Name: fIRUiplk COJKtut.r►pi, E$NtrgLS Person to contact should erosion & sediment
Address: 0 17.0'p( 2,01r7 control issues arise during land-disturbing activity:
MCI t NC, 2756 2 Contact Person: $►fly Qp►a Ra-t cc
Contact Person:S( bb% Q#,JAr4- Company Name: ?1N 11LtLo C Mc yet c-1)u►4 C e RP
Phone: g 19 $‘3 1 y'i-Z- Phone: 914 2$5'1$95
E-Mail: �,Allincarcadi.e"ti►nc¢:s,'- ' E-Mail: b,1(Aef.on►ar'-c0(ons+1-0.c*;6V\ u,..".
Page 2 of 3 ANTICIPATED START DATE: 121141102,3 hOV3 ANTICPATED END DATE: 042412 3

Soil Erosion and Sedimentation Control
CHA-rHAM CC)UNTY
fit ` isC A IA..1 ` Ad A Financial Responsibility/Ownership Form
NOT REQUIRED TO BE COMPLETED FOR RESIDENTIAL LOT PERMITS.
PLEASE READ THE FOLLOWING INFORMATION:
l)This section must be signed in the presence of a Notary.
2)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.
3)This form must also be signed by the financially responsible party and NC agent(if applicable).Same provisions of#2 above apply.
4)If the landowner and financially responsible party are different,the completion and signing of this page shall serve as documentation
acknowledging the landowner consents to and authorizes the financially responsible party to undertake the proposed land-disturbing activity on the
landowner's tract(s)of land identified on this application.
5)The information provided on this form is true and correct to the best of my knowledge and belief and was provided by me while wider oath.
6)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 S5000.00 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.
OWNER OF PROPERTY:
Name and Title: DDP\l 54'10
Company(if applicable):
Signature:
FINANCIALLY RESPONSIBLE PARTY(applicable only if different from property owner):
Name and Title:
Company: -
Signature:
NORTH CAROLINA AGENT(if ally):
Name and Title:
Company: -
Signature:
******** **^i'1'9'****x***********************************************
i, elLiqct r+Nta 1kid j4o/ , a Notary Public of ko _County in the state
of NE)1(L&' Lout) i)a do hereby certify that f n 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 .2Z day of f27Q L ,202
o;`N1GA M 01011 meow ,,
Notary Pu c S10y�`�9y
My commission expires l - De - 2-C ' � y i
0BL%C /
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