Undisturbed Open Space Mitigation Application Form
Mecklenburg County Land Use and Environmental Services Agency
Application Recvd. Date:
Form #PCO15
(rev. 2/2013)
Time:
Application/Permit Number:
O
Information Regarding Site Where Mitigation is Requested:
Name of Development:
Street Name & Number:
Original Tax Parcel:
Name of Creek System Where Development is Located:
Total Area of Project (acres):
Total Disturbed Area (acres):
% Built Upon:
Total Area of Open Space Area to be Mitigated (acres):
Grass Field: Yes
No
Fee Paid: $
Amendment to Permit #:
Type of Development:
Commercial
Residential
Mixed Use
Subdivision
Jurisdiction/Town:
Zoning Designation:
Resubmittal:
Yes
No If yes provide notification date that resubmittal was required:
Owner’s Name:
Owner’s Address:
Owner’s Phone Number:
Fax:
Owner’s Email:
Explanation as to how all reasonable efforts have been undertaken to fulfill Undisturbed
Open Space requirements on the site:
Option #1: On-Site Mitigation Option:
Total Area of On-Site Mitigation Area (acres):
Total Number of Trees to be Planted (minimum of 36 trees per acre):
Option #2: Off-Site Mitigation Option
Size of Off-Site Mitigation Area (acres):
Mitigation Area Street Name & Number:
Tax Parcel:
Named Creek System Where Mitigation Area is Located:
Jurisdiction/Town:
Zoning Designation:
Property Owner’s Name:
Owner’s Address:
Owner’s Phone Number:
Fax:
Owner’s Email:
Option #3: Payment-In-Lieu Mitigation Option
Appraised Value of Open Space Area to be Mitigated Including Intended Use Without
Improvements (appraisal must be performed by licensed appraiser) = $
Total Payment at 1.25 x Appraised Value = $
IMPORTANT: Check must be made payable to applicable Jurisdiction.
This application conveys the information necessary for the review of a request for the three (3) Undisturbed Open Space mitigation options,
including Option #1 On-Site Mitigation, Option #2 Off-Site Mitigation and Option #3 Payment-In-lieu. This application shall be reviewed and
approved at the same time as the Concept Plan for the project. Approval of this application runs contiguous with the Storm Water Management
Permit issued for the site which is valid until the project is complete or three (3) years from issuance of permit, whichever comes first. The
information listed on the back of this form must be enclosed for the option(s) form in order for the application to be complete.
Reviewed By: _______________________________________ Date: _____________________
Approved
Approved with Modifications
Approved with Performance Reservation (attached)
Approved By: _______________________________________ Date: _____________________
Option #1: On-Site Mitigation:
Please check off the items below that are enclosed with the On-Site Mitigation Application. All
items must be checked in order for an application to be considered complete.
1.
Planting plan for the proposed mitigation area including the following:
• Location of all trees.
• Tree caliper (must be a minimum of 1.5 inches).
• Tree species (must show a minimum of three (3) different species in roughly equal
proportions selected from the list in Appendix 6-6 (Form #PCO14) of the Administrative
Manual).
• Statement as to the quality of the trees as set forth by the American Standard for Nursery
Stock.
• Material used to stabilize the area around and between trees (must be vegetative ground cover
and mulch).
• Contours of final grade at two (2) foot intervals extending 100 feet beyond the property
boundary (Slope of any Graded or Disturbed Area for On-Site Mitigation can not exceed 3 to
1).
• Methods for the controlling the flow of water across the area to prevent soil erosion or mulch
disturbance.
• Depth of top soil (minimum of six (6) inches).
• The scale of the plan, which shall not be smaller than 100 feet to the inch; north point; date.
• A small scale vicinity map.
2.
Written specifications for the planting of trees and groundcover.
3.
Written warranted statement for the replacement of dead or diseased trees over a minimum of two
(2) years following planting.
Option #2: Off-Site Mitigation:
Please check off the items below that are enclosed with the Off-Site Mitigation Application. All
items must be checked in order for an application to be considered complete.
1.
Map of the site to be used for mitigation including the following:
• North arrow.
• Vicinity map.
• Legible scale (not to be smaller than 100 feet to the inch).
• Property boundary and adjoining property boundaries and owners.
• Buildings and other improvements located on or immediately adjacent to the site.
• Description of existing vegetative cover.
• Location of any surface waters on or adjoining the property.
• North point
• Date.
2.
A legally valid instrument demonstrating that the applicant has legal title to the property for
transfer to the jurisdiction.
3.
Phase I environmental site assessment identifying areas of concern on or immediately adjacent to
the site
Option #3: Payment-In-Lieu Mitigation:
Please check off the items below that are enclosed with the Payment-In-Lieu Mitigation
Application. All items must be checked in order for an application to be considered complete.
1.
Approved appraisal prepared by a licensed, independent real estate appraiser.
Application Submittal Requirements:
This application must be submitted at the same time and attached to the Concept Plan Application form.