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DAWSON COUNTY Department of Planning & Development Project Name: Site Address/Location: Tax Map /Parcel Number: Property Owner: email address: Developer/Builder Name: Certification Number: 24 Hour Emergency Contact for Soil Erosion Issues: Phone: Proposed Use of Land: Amount of Land to be Disturbed: Application is hereby made according to the Land Use Resolution of Dawson County, Georgia, the Subdivision Regulations of Dawson County, Georgia, the Storm Water Management Ordinance of Dawson County, Georgia and applicable laws and regulations, including, but not limited to, the Soil and Sedimentation Control Ordinance of Dawson County, Georgia. I agree to comply fully with all requirements of above reference laws and regulations. I understand that these documents are available for my review and that infractions may cause immediate revocation of this permit and the stoppage of all work. Owners Signature: Date: Staff Review: Permit Application date: NRCS Approval date: REQUIRED SIGN