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Land Disturbance Permit Updated 1/30/2019 Permit # Fee NOI Submittal # Paid: ☐ Check ☐ Cash Date CONSTRUCTION LOCATION: Address: Parcel Disturbed Acres: Property Owner Information Contractor Information Name of 24 Hour Contact Contact Business License State License Printed Name of Signature of Initial_______ I hereby certify that I fully understand the provisions of the Greene County Erosion and Sediment Control Ordinance and Program, and that I accept responsibility for carrying out the Erosion and Sediment Control Plan for the above referenced project as approved by the County. Initial_______ I further grant the right-of-entry onto this property, as described above, to the designated personnel of Greene County for the purpose of inspecting and monitoring for compliance with the aforesaid Ordinance. your Submit SIGNED application to the Greene County, GA permits office at [EMAIL REDACTED] or in person at 1034 Silver Dr, Ste 103, Greensboro, GA 30642. Fields in red or REQUIRED fields. SEPTIC LETTER OBTAINED YES NO Greene County Building Inspection Division Chuck Wooley Building Official 1034 Silver Dr., Ste 103, Greensboro, GA 30642 Telephone [PHONE REDACTED] www.greenecountyga.gov LAND DISTURBANCE PERMIT