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Thomson-McDuffie Planning Commission 210 Railroad Street, Suite 1544 Thomson, Georgia 30824 [PHONE REDACTED] Land Disturbance Permit Application Project Project Parcel Land Disturbance Permit Type: [ ] Minor [ ] Major [ ] Exempt Project Details: [ ] Part of Common Dev [ ]Stand Alone Res [ ] Stand Alone Com [ ]Common Dev [ ]Infrastructure [ ] Other Total & Disturbed Project Proposed Date of Property Owner of Mailing Mailing 24- Hr Contact 24- Hr Engineering Contact Notice of Intent (NOI) [ ]Primary [ ]Secondary [ ]Tertiary [ ]N/A Date NOI submitted to Georgia Environmental Protection *Must show proof of submittal date either by GEOS generated submittal receipt or EPD stamp on front page of the NOI. NOI fee: acres disturbed (round off to the nearest tenth) x $40/acre = [ ]Check attached Limits of Disturbance within 200-feet of State Waters: [ ]Yes [ ]No Flood Plain: [ ]Yes [ ]No Plan Type: [ ]Erosion, Sedimentation, and Pollution Control Plan [ ]Grading Plan [ ]Plot Plan Attachments included- Check ALL that apply: Erosion, Sedimentation & Pollution Control Plan Checklist for: [ ]Stand Alone Construction Projects [ ]Common Development Construction Projects [ ]Grading Checklist [ ]Stormwater Checklist [ ]Infrastructure Checklist [ Plan Barcode [ ] NOI [ Certification (required for all projects with a NOI) Certification Office Use Only: Application Fee: Received Application: [ ]Approved [ ]Approved w/Conditions [ ]Disapproved Special Conditions: 1. This permit is only valid after signed by the Zoning 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 Planning and Zoning. 4. This permit is non-transferrable 5. Plan Approval NOI Approval NOI Fee: [ ]Yes [ ]No Amount Paid: [ ]Yes [ ]No Date Zoning Director (or designee):