Simplified Land Disturbance Application (One Acre Or Less & Generating Less Than One Cfs)

GREENVILLE COUNTY, SOUTH CAROLINA

Revision Date: 2/25/2016

STORMWATER MANAGEMENT/SEDIMENT CONTROL PLAN

LAND DISTURBANCE PERMIT

SIMPLIFIED APPLICATION FORM

USED FOR: ONE (1) ACRE OR LESS & GENERATING LESS THAN ONE (1) CFS

$500.00.

Plan Review Fee Amount

If yes, additional fee is: $500.00; this

Unauthorized Land Disturbance Fee: ___

Yes ___ No

will be added to your Plan Review Amount. Remediation Fee Amount: ______________ Total Fee(s): ____________

(*Note: Remediation Fee is $150.00 per disturbed acre. This fee is a monetary performance guarantee for every new development. This guarantee will

provide assurance that all exposed soil surfaces will be stabilized in the event a development discontinues.

Date: _______________ Project/Site Name: ___________________________________________Tax Map No. ______________________________

Site Address: _____________________________________________________________________________________________________________

Jurisdiction: ___ Unincorporated or City Limits of: ___ Fountain Inn

___ Mauldin

___ Simpsonville

___ Travelers Rest

Permit No. ________________Building Permit No. (if known): ________________ Complaint/SWO/Violation No. (if applicable): _____________

Person financially responsible for the land disturbing activity: __________________________________________________________________

Street Address: _____________________________________________ City: ___________________________ State: _____ Zip: _________

Phone No. (Day): _______________________ Ext. ____ Mobile/Night No. ____________________ Fax No. ___________________________

Is this person also the owner of the land? ___ Yes ___ No

If no, proceed to no. 3

Name of Owner: _____________________________________________________________________________________________________

Street Address: _____________________________________________ City: ___________________________ State: _____ Zip: _________

Phone No. (Day): _______________________ Ext. ____ Mobile/Night No. ____________________ Fax No. ___________________________

Name of Engineer, Surveyor, or Point of Contact: ___________________________________________________________________________

Street Address: _____________________________________________ City: ___________________________ State: _____ Zip: _________

Phone No. (Day): _______________________ Ext. ____ Mobile/Night No. ____________________ Fax No. ___________________________

Name of Grading Contractor: ___________________________________________________________________________________________

Street Address: _____________________________________________ City: ___________________________ State: _____ Zip: _________

Phone No. (Day): _______________________ Ext. ____ Mobile/Night No. ____________________ Fax No. ___________________________

Property Size-Total (acres): _______ Disturbed Area

: ______ Start Date: _____________ Completion Date: ___________

(to the nearest 10

)

Nearest receiving water body/distance to: _________________________________________________________________________________

Are there any freshwater wetlands on the property? ___Yes ___ No If yes, have the wetlands been delineated by an Engineer? ___ Yes __ No

If yes, attach report or plan (Note: A freshwater wetland is land covered by water some or all of the time. If answered no, and wetlands are found

on this site during inspection, this permit will be revoked and turned over to SCDHEC.)

Has Greenville County issued a Notice of Violation to comply for this site or LCP? ___ Yes ___ No

If yes, please attach Violation with application.

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

If yes, please attach SPA Permit with application submittal.

10. Is site a part of a Zero Lot Land Disturbance Permit? ___ Yes ___ No If yes, list permit #: _________________________________________

11. Narrative description of the nature of construction activity: _____________________________________________________________________

___________________________________________________________________________________________________________________

12. Description of Best Management Practices (I.E: erosion control measures) to be used (Also Show On Plans): ____________________________

______________________________________________________________________________________________________________________________

13.

I hereby certify that all land Disturbing Construction and Associated Activity pertaining to the 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. Permit pickup is

required within 20 business days of notification to avoid application re-submittal. This does not apply to projects associated with a Notice of Violation. Such

projects must be picked at the time specified at the time of notification.

I hereby grant authorization to DHEC and/or Greenville County (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 OWNER

OWNER SIGNATURE (sign in BLUE INK)

DATE

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