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):
Less than 1 AcreGreater than 1 Acre
YesNo
24-Hour Emergency Contact:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate:
Erosion & Sedimentation Control
YesNo
GSWCC Approval Date:
YesNo
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: *

Clear
Date*

MonthDayYear
Date
Should be Empty:

Land Disturbance Permit Application

Property Owner

Applicant/ Contractor

Project Information

Erosion & Sedimentation Control

Fees