City of Byron - Land Disturbance Permit Application

Land Disturbance Permit Application

401 Main Street Byron, GA 31008. 478-956-3600
Date

MonthDayYear
Date
Permit No.:
Estimated Cost of Project (Labor & Materials): $
JOB SITE ADDRESS:
PROJECT NAME:
Zoning Class:
Map & Parcel:
DESCRIPTION OF LAND DISTURBANCE ACTIVITY:
Property Owner
Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Applicant/ Contractor
Name:
Company:
GA License No.:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Project Information
Total Disturbed Area (Acres):
Within 200 ft. of State Waters
24-Hour Emergency Contact:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate:
Erosion & Sedimentation Control
GSWCC Approval Required:
GSWCC Approval Date:
Initial E&S Measures Installed
Fees
Disturbed Area (Acres):
Administrative Fee:
Plan Review Fee:
Total Fee:
NOTICE

No changes shall be made from that which is stated in this application or in attached plans except by submitting a revised application and receiving approval. Approval of this permit does not authorize any violation of local, state, or federal law, including erosion and sedimentation requirements under O.C.G.A. 12-7.

Projects disturbing more than one (1) acre or within 200 feet of State Waters require a Land Disturbance Activity Permit (LDAP) and Notice of Intent (NOI) submitted to the State. Erosion control plans must be approved by GSWCC.

Certification

I hereby certify that I have read and examined this application and that all information provided is true and correct. All work will comply with applicable ordinances and regulations.
Applicant Signature:
Date

MonthDayYear
Date
Should be Empty:

Land Disturbance Permit Application

Property Owner

Applicant/ Contractor

Project Information

Erosion & Sedimentation Control

Fees