Land Disturbance Permit Application Form - Greenville County

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RECEIVED DATE:

GREENVILLE COUNTY, SOUTH CAROLINA

(for official use only)

STORMWATER MANAGEMENT/SEDIMENT CONTROL PLAN

LAND DISTURBANCE PERMIT APPLICATION

To Be Used For: ONE (1) ACRE OR OVER and INCREASING FLOWS BY ONE

CFS OR MORE and/or Engineered Minimum Projects

(to be included with SCDHEC’s NOI, pages 1 - 3 )

DATE: _________________ PROJECT/SITE NAME: ___________________________________________________________________________

TAX MAP NO: __________________________________________________________________

PERMIT NO: __________________________

PREVIOUS PERMIT NO. (

BUILDING PERMIT NO.(

______________

If previously permitted and/or part of a master plan) ___________________

if known):

l. Site Information:

A. Has Greenville County issued a Notice of Violation to comply for this site or LCP? ___ Yes ___ No Violation #: __________ If yes, please

submit the Unauthorized Land Disturbance Fee a copy of the Notice Of Violation.

B. SIC Code:

(SIC Code only required for sites disturbing more than 5 acres-refer to instruction sheet for code information)

C. Flood Plain: ___ Yes ___ No

If yes, designate Flood Plain on site plan and provide letter from Flood Plain Manager or municipality with jurisdiction.

D. Jurisdiction:

___ Unincorporated or City Limits of:

___ Fountain Inn

___ Mauldin

___ Simpsonville

___Travelers Rest

E. Does this site require a U.S. Army Corps of Engineers (USA COE) Permit? ___ Yes ___ No

If yes, please attach COE Permit with application

submittal.

F. Does this require a Special Pollutant Abatement Permit (SPA) Permit? ___ Yes ___ No

If yes, please attach SPA Permit with application

submittal.

G. Is there a Tree Protection Plan or Municipal Landscaping Plan for this site? ___ Yes ___ No

If yes, an approval letter must be obtained from

Building Codes (commercial), Planning Commission (subdivision), or municipality with jurisdiction, prior to Grading Permit issuance.

If no, an exemption letter must be obtained from Building Codes (commercial), Planning Commission (subdivision), or municipality with jurisdiction,

prior to Grading Permit issuance.

Signatures and Certifications: (

ll.

DO NOT SIGN IN BLACK INK or USE Electronic, Scanned, or Copied Signatures)

A. I hereby certify that all land disturbing construction and associated activity pertaining to this site shall be accomplished pursuant to and in

keeping with the terms and conditions of the approved plans. I also certify that a responsible person will be assigned to the project for day-to-

day control. I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in

accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on

my inquiry of the person or persons who manage the design system or those directly responsible for gathering the information, the information

submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for

submitting false information, including the possibility of fine and imprisonment for knowing violations.

I hereby grant authorization to the Department of Health and Environmental Control and/or the local implementing agency the right

of access to the site at all times for the purpose of on site inspections during the course of construction and to perform maintenance

inspections following the completion of the land disturbing activity.

Printed name of Primary Permittee

Signature of Primary Permittee

Title/Position

Date

B. Designer Certification – The requested copies of the site plans folded & stapled in sets, all specification and supporting calculations, forms, and

reports are herewith submitted and made part of this application. I have placed my signature and seal on the design documents submitted

signifying that I accept responsibility for the design of the system. Further, I certify to the best of my knowledge and belief that the design is

consistent with the requirements of Title 48, Chapter 14 of the Code of Laws of SC, 1976 as amended, and pursuant Regulation 72-300, and

County Ordinance: 4281.

Prior to approval, for all permanent stormwater management features, I will submit a statement and an as-built certifying that

construction is complete and in accordance with approved plans and specifications. This will be based upon periodic observations of

construction and a final inspection for design compliance by me or a representative of my office who is under my supervision. (To be signed by

a registered professional responsible for construction)

Check one:

___ Engineer

___ Tier B, Surveyor

___ Landscape Architect