2. 
6. Site Information:
8. Property Address*
9. Tax Map No./Legal Description*
11. Subdivision / Project Name*
13. Total Area of Site (Acres/SqFt)*
14. Total Area to be DISTURBED (Acres/SqFt)*
16. Will there be Stormwater Management for this site?

    1. YES

    1. NO
20. Applicant Information:
22. Applicant Name*
24. Applicant Address*
26. Applicant City*
27. Applicant State*
28. Applicant Zip*
30. Phone #:*
31. Email Address*
33. * If applicant is NOT Property owner of Record, the Power of Attorney Form is required.
35. Property Owner of Record*
37. Owner Address*
39. Owner City*
40. Owner State*
41. Owner Zip*
43. Phone #:*
44. Email Address*
48. Licensed Professional (Professional Engineer or Land Surveyor):
50. Firm Name*
51. Contact Name*
53. Address*
55. City*
56. State*
57. Zip*
59. Phone Number*
60. Email Address*
62. Professional License #:*
66. Select Primary Contact Person for Staff:*

    1. Owner

    1. Applicant

    1. Licensed Professional
70. Certified Responsible Land Disturber Name*
    This individual will be responsible for signing the approved permit.
72. RLD Phone #:*
73. Email Address
75. RLD Number:*
76. RLD Expiration Date*
    RLD Expiration Date
80. SIGNATURE:
82. I have submitted all information to the best of my knowledge.
84. Signature of Applicant*
85. Date*
    Date
Leave This Blank:


89. 1. Receive an email copy of this form.
90. Email address

    This field is not part of the form submission.

91. Submit Submit and Print

* indicates a required field