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Land Disturbance Permit Application Questions? Call: (706) 447-7645 [SOIL] / Email: [EMAIL REDACTED] Make all checks payable to 'Columbia County' Mailing address: Stormwater Compliance P.O. Box 498 Evans, GA 30809 Street Address: 630 Ronald Reagan Dr., Bldg A, East Wing Evans, GA 30809 General Conditions, Legal Authority, Certification, & Required Signature on following page Rev. 07/2022 Page 1/2 PROJECT Project Description: Lot : Project Address: Parcel ID: Land Disturbance Permit Type: Clearing & Grading Minor Major Exempt Project Details: b Part of Common Dev Stand Alone Res Stand Alone Com Common Dev Infrastructure Other Total & Disturbed Project Acres: Proposed Date of Construction: OWNER & APPLICANT & ENGINEER Property Owner of Record: Phone Mailing Address: Email: Operator/Contractor: Phone Mailing Address: City/State: Email: 24-Hr Contact Name: 24-Hr Contact 24-Hr Email: Engineering Firm: Phone Contact Person: Email: ENVIROMENTAL Notice of Intent (NOI): Primary Secondary Tertiary N/A Date NOI submitted to Georgia Environmental Protection Division*: *Must show proof of submittal date either by GEOS generated submittal receipt or EPD stamp on the front page of the NOI NOI fee: acres disturbed (round off to the nearest tenth) x $45/acre = Check attached Limits of Disturbance within 200-ft of State Waters: Yes No Flood Plain: Yes No For residential projects: If you are building a livable structure that is located within the Special Flood Hazard Area (SFHA), as mapped by FEMA, an elevation certificate is required. Elevation Certificate Required: Yes No REQUIRED DOCUMENTS Plan type: Erosion, Sedimentation and Pollution Control Plan Grading Plan Plot Plan Attachments included (per the permit table found in Chapter 34-70 of the Ordinance) – check ALL that apply: Erosion, Sedimentation & Pollution Control Plan Checklist for: Stand Alone Construction Projects Common Development Construction Projects Certification (required for all projects with a NOI) OFFICIAL USE ONLY Application fee: Received By: Application: ☐ Approved ☐ Approved w/Conditions ☐ Disapproved [Col. Cty Code of Ordinance, 34-70(b)(5)a] Special Conditions: 1. This permit is valid only after signed by the Engineering Services Director (or designee) 2. E&SC Bond required (irrevocable letter of credit) ☐ No ☐ Yes Amount 3. No site work shall begin until after a pre-construction meeting is held by the Environmental Services Department (as required by LDP table) 4. This permit is non-transferrable 5. Other Plan Approval Date: NOI Approval Date: NOI Fee: ☐ Yes ☐ No Amount Paid: ☐ Yes ☐ No Date Paid: Received By: Engineering Services Director (or designee) Date Name: Certification Grading Checklist Stormwater Checklist Infrastructure Checklist NOI ---PAGE BREAK--- Land Disturbance Permit Application Rev. 07/2022 Page 2/2 GENERAL CONDITIONS LEGAL AUTHORITY In accordance with Columbia County Code of Ordinance, Chapter 34 Environmental Article III, 34-70(b)(5) Denial of permit. If a permit applicant has had two or more violations of previous permits, this article, or the Georgia Erosion and Sedimentation Act, as amended, within three years prior to the date of filing of the application under consideration, the county may deny the permit application pursuant to O.C.G.A. 12-7-7(f)(1). 34-70(b)(6) Bond requirement. The county may require the permit applicant to post a bond in the form of government security, cash, irrevocable letter of credit, or any combination thereof up to, but not exceeding, $3,000.00 per acre or fraction thereof of the proposed land-disturbing activity, prior to issuing the permit. If the applicant does not comply with this article or with the conditions of the permit after issuance, or the bond, the county may call the bond or any part thereof to be forfeited and may use the proceeds to hire a contractor to stabilize the site of the land-disturbing activity and bring it into compliance. 34-70(d)(4) The permit may be suspended, revoked, or modified by the county, as to all or any portion of the land affected by the plan, upon finding that the land-disturbing activity is not in compliance with the approved ESPC plan or the permit or that the holder or his successor is in violation of this article. A holder of a permit shall notify any successor as to all or any portion of the land affected by the approved plan of the conditions contained in the permit. CERTIFICATION I hereby certify that the information provided herein is true, correct and complete to the best of my knowledge. I further certify that I have read the stipulations in this application and that I, and/or the entity I represent, as applicable, will be subject to these stipulations if a permit is issued. Operator/Contractor (Print ) Owner/Developer or Authorized Representative (Print) Date Owner/Developer or Authorized Representative (Sign) a. Projects that include the impoundment of water or the construction of a pond, the owner hereby agrees and does by these presents, indemnify and hold harmless Columbia County, Georgia from and against any and all claims, demands, suites. Judgments, or chooses-in-action which may be a third party against Columbia County, Georgia, as a result of the impoundment of water or the construction of a pond covered by this permit. b. Applicant indemnifies and holds the Columbia County, Georgia and its officers, agents, and employees against any and all claims, damages, demands, actions, causes of action, costs and expenses of whatsoever nature, which may result from any injury, death, loss or damage arises out of the construction, operation, maintenance, repair, removal or relocation of the facilities covered by this permit. c. Applicant is responsible for submitting all applicable documents, plans, reports, and/or drawings to comply with theLand Disturbance Permit Table and Columbia County Ordinance d. Applicant is responsible for obtaining any additional permits required by Georgia DOT, GA EPD, GA DNR, USACE &/or other government agencies. e. This permit is subject to modification or revocation on a finding of noncompliance with any of the provision of the Columbia County Soil Erosion and Sedimentation Control Ordinance, and/or Erosion and Sedimentation Act of 1975, as amended, or any of the rules promulgated pursuant thereto; or with any representation made on the attached thereto. f. Unless otherwise exempted, person engaged in land-disturbing activities shall apply erosion and sedimentation control measures which conform to the specifications contained in the current version of the "Manual for Erosion and Sediment Control in Georgia" (also known as the "Green Book") published by State Soil and Water Conservation Commission. g. Once approved, this permit is effective until completion of the aforementioned land disturbing activity. However, if the land disturbing activity does not commence within twelve (12) months from date issued, or construction ceases for a period of 90 days, this permit will become null and void. h. The contractor will adhere to the weight limits prescribed on County maintained roads for hauling equipment and/or materials to and from this site. The contractor will be held responsible for any damages to the streets and/or utilities due to non-compliance of weight limit regulations. i. Failure to comply with the terms of this application will result in an immediate Stop Work Order in accordance with Columbia County Code of Ordinance, Chapter 34-72 j. The following projects are exempt from the permit requirements of Columbia County Ordinance Section 34-70, provided however any land disturbing activities conducted as part of any such project shall conform to the minimum requirements as set forth in Ordinance Section 34-69, including, but not limited to, the implementation of BMPs, and the level of documentation specified in the LDP table shall be submitted to the County for verification in advance of undertaking such activity: 1) Project with land-disturbance of less than 1000-square feet and not within 200-feet of State Waters. 2) Individual new home construction within a larger common plan of development with an open Primary Notice of Intent, and such individual new home construction will be conducted in conformance with the approved development plan and ESPC plan applicable to the lot affected. 3) Minor land-disturbing activities such as home gardens and individual home landscaping, repairs, maintenance work, fences, etc. 4) Excavations and related preparations for establishment of irrigation wells not part of a bona-fide agricultural operation under O.C.G.A. 1-3-3. SIGN