Fillable 396 Application For Land Disturbance Permit (City of Murfreesboro)

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396 Application For Land Disturbance Permit (City of Murfreesboro)

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(continued on reverse)
Planning & Engineering No.
Priority Activity / 303d
Stream
Inspector/area
Permit Number
LP
SWPPP Approved
MWSD File No.
Pre-Con Insp. Passed
Threatened &
Endangered
Aquatic Fauna
Flora
Fauna
Latitude
Longitude
Received Date
Application for Land Disturbance Permit
City of Murfreesboro
Project name; permit applicant information
Description of property
Description of land disturbance; nature, extent and purpose
CITY USE ONLY
Project name:
Applicant name:
Address:
Zip
City:
DC:
Cell no.:
Contact person:
Signature of owner or officer:
No
Yes
Is this an application for renewal of an existing Land Disturbance Permit?
State
E-mail:
Address:
Legal description:
Tax reference no.
Parcel no.
acres
acres
Will fill material be brought onto site?
Yes
No
Will excavated material be removed from site?
If Yes, is the other site covered by a Land Disturbance Permit?
Total acreage:
Project Acreage:
Office ph. no.:
Owner of property of record:
Yes
No
No
Yes
Group (optional)
Map #
Example: 091 AA 001.00
Map #
Group #
Parcel #
Start Date:
Completion Date:
Print Form
TN
Reset Form
LDP Application March.2005 rev.
Contractors in charge of land disturbing activity & installation and maintenance of erosion prevention and sediment
control measures
Water Quality – Related Issues
Provide copy of State of Tennessee (TDEC) NOI for Construction General Permit.
This construction will involve the following; indicate number of each:
General contractor:
Address:
City:
State
Contact person:
E-mail:
Office ph. no.:
Cell no.:
DC:
Other contractor:
Responsibility:
Address:
City:
State
Contact person:
E-mail:
Office ph. no.:
Cell no.:
DC:
List streams that receive water runoff from site:
No of sinkholes on property?
No. of wetlands on property?
If the State has issued permit coverage, provide permit tracking no.: TNR14
Alteration of wet-weather conveyances
Construction road crossings of waters
Stream crossings for utilities
Alteration of wetlands
Improvement to sinkholes
Stream restoration or bank stabilization
Submit completed application to
Planning and Engineering Department
111 West Vine Street
Murfreesboro, TN 37130
For more information contact:
Building & Codes at (615) 893-3750
Planning and Engineering at (615) 893-6441
Water and Sewer at (615) 848-3200
http://www.murfreesborotn.gov/government/
water_sewer/ldp.htm
Permit will be issued by Building & Codes Department (2nd Floor, City Hall). Applicant must show proof of Tennessee
Contractor's License and current workman's compensation, in addition to payment of Land Disturbance Permit fee.
TN
TN
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396 Application For Land Disturbance Permit (City of Murfreesboro)

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Completed 4 August 2020

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