APPLICATION FOR LAND DISTURBANCE
Instructions: An application for a permit must include the applicant’s Site Grading and Drainage Plan,
including an Erosion and Sediment Control Plan along with sufficient engineering calculations to verify
storm-water discharge(s). The plans must be factual and complete and submitted in duplicate to the City
of Semmes Public Works Department along with payment of the appropriate fee.
The undersigned hereby applies for a permit for the activity represented on the attached plans. Land
Disturbance Permit Fees are $20.00. Permit will be issued upon approved inspection of property by QCI
Inspector-particularly erosion and sediment control measures in place: construction site driveway in place,
to prevent transfer of mud, clay, sand or debris, onto public roadways, dumpster in place for site debris and
construction debris containment, and placement of temporary toilet facilities.
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Land Owner / Applicant Name Contractor Name
_______________________________________ ______________________________________
Street Address Street Address
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City, State, Zip Code City, State, Zip Code
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Telephone Number Telephone Number
_______________________________________ ______________________________________
Land Owner / Applicant Signature Contractor Signature
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Acreage to be disturbed Parcel Number
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City of Semmes Inspector Signature Date
Approval of the Land Disturbance Permit is NOT authority to initiate construction. The applicant is
responsible for obtaining the necessary approvals and insuring compliance with applicable ADEM, Zoning,
Subdivision, and any other Ordinances or Regulations.
