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PICKENS COUNTY APPLICATION FOR LAND DISTURBING PERMIT Project File # Date of Application Date of Submittal to Limestone Valley SWCD: Any State Waters Onsite or Within 200’ of this Site: Yes No Applicant Must be Level 1A Certified (provide number) (Full Name) (Business Phone) (Address) Landowner (Full Name) (Business Phone) (Address) Plan prepared by Must be Level 2A Certified (provide number) Project (Name and Description) Location Land Lot Total Acres Disturbed I, hereby certify that I fully understand the (Signature) Must be Level 1A Certified provisions of the Pickens County Erosion and Sediment Control Ordinance Program, and that I accept responsibility for carrying out the Erosion and Sediment Control Plan for the above referenced project as approved by the Pickens County Land Development Office. I further grant the right-of-entry onto this property, as described above, to the designated personnel of Pickens County for the purpose of inspecting and monitoring for compliance with the aforesaid Ordinance. Approved (Local Issuing Authority) Date (Other Official) Date