Fillable LAND DISTURBING PERMIT (Town of Ashland, VA)

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LAND DISTURBING PERMIT (Town of Ashland, VA)

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Page 1
LAND DISTURBING PERMIT
Effective Date: Permit Number
Expiration Date:
Application Type Fee Attached
SINGLE FAMILY DWELLING………………………………………………….………….……………. $300
LAND DISTURBANCE (COMMERCIAL/RESIDENTIAL) ………………….…………………. $300 + $50/acre or part
SHORT TERM (60-DAY) LAND DISTURBING (RESIDENTIAL ONLY) ……………….… $150
ANNUAL RENEWAL – ACTIVE SITE…………………………………………………..……………. 100% of original fee
ANNUAL RENEWAL – DORMANT SITE………………………….....……………………………. 50% of original fee
Applicant:
Name
Address
City State Zip
Phone Email
Property owner:
Name
Address
City State Zip
Phone Email
Project:
Site Plan or Building Permit Number
Physical Address
Subdivision / Lot Number
GPIN(s)
Total Lot Size Disturbed Area
Attachment (must select one):
For Detached Single Family Dwellings: Agreement in Lieu of Erosion and Sediment Control, Water Quality and
Stormwater Management Plans for a Single-Family Residence
For all other Projects: Page 2 of Land Disturbing Permit
APPROVED:
TOWN OF ASHLAND
BY: Bond Amount
TITLE: Director of Public Works Date Received
DATE: Type of Payment
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Page 2
Rev 12/2020
I hereby certify that I fully understand the provisions of the Town of Ashland Erosion and Sediment Control Ordinance and
Program, and that I accept responsibility for carrying out the Erosion and Sediment Control Plan for the above referenced
project as approved by the Town. I have read and understand the attached requirements of this permit and grant the
right-of-entry onto this property, as described above, to the designated personnel of the Town of Ashland for the purpose
of inspecting and monitoring for compliance with the aforesaid Ordinance.
The following general statements apply to all permits:
1. All projects shall conform to the Minimum Standards expressed in the
Virginia Erosion and Sediment Control
Regulations, effective September 13, 1990, and as amended from time-to-time.
2. This permit and a copy of the approved plan must be kept on the work site and shown when requested.
3. The limits of disturbance, wetlands and Chesapeake Bay protection areas must be flagged by the owner/owner’s
representative and checked by Town Inspector prior to beginning work on site.
4. The Town must be notified when work commences and when the project is completed.
5. Other work (grading, excavating, construction) on the project shall not commence until the appropriate erosion and
sediment controls are in place as specified on the plan, and approved by the Town Inspector.
6. Applicant agrees to be responsible for any and all damages to any other installations already in place as a result of
work covered by this permit.
7. Applicant agrees to maintain the erosion and sediment control measures in satisfactory operating condition until
final, permanent stabilization is achieved.
8. The land-disturbing permit may be revoked if the Town of Ashland determines that the project is not in compliance
with the conditions of the approved plan, or if the applicant fails to implement the approved plan.
9. An approved plan may be changed by the Town if inspection has revealed the inadequacy of the plan to satisfy
applicable regulations.
Section 5.5 of the Ashland Town Code requires that a Performance Guarantee be posted with the Director of Public Works
in the amount approved by the Director of Public Works. Such Guarantee shall be conditioned to conform any work to
approved standards, specifications and criteria as set out in the Approved Erosion and Sediment Control Plan. Final
inspections of the project shall be made by the Town of Ashland and the release of the Performance Guarantee is
contingent upon the findings of such inspections. Release shall occur within 60 days after disturbed areas are deemed
adequately stabilized by the Director of Public Works or designee.
Signature of Responsible Land Disturber
Printed Name: RLD Number:
STATE OF VIRGINIA
COUNTY OF HANOVER
The foregoing instrument was acknowledged before me this _____day of _______________, 20_____
By ______________________________, Responsible Land Disturber.
My Commission Expires: _______________ NOTARY PUBLIC___________________________________
Page 1 of 2
TOWN OF ASHLAND DEPARTMENT OF PUBLIC WORKS
(804) 752-6875
AGREEMENT IN LIEU OF EROSION AND SEDIMENT CONTROL, WATER QUALITY, AND STORMWATER MANAGEMENT
PLANS FOR A SINGLE-FAMILY RESIDENCE
Th
is Agreement is issued in place of an Erosion and Sediment Control Plan, a Water Quality Plan, and a Stormwater
Management Plan for a Single-Family Detached Residential Structure. It is valid only when signed by all parties and is
accompanied by a Town of Ashland Land Disturbing Permit. Its authority is contingent on compliance with the following
requirements:
A. Erosion and Sediment Control: Permittee shall adhere to the Minimum Standards of the Virginia Erosion and Sediment
Control Regulations, the Town of Ashland Erosion and Sediment Control Ordinance and the following:
1. Attach plot plan to this agreement for Town of Ashland (TOA) review and approval. Plan shall show, at a
minimum,
site boundary, buildings, driveways, walkways, erosion and sediment control measures, existing
and proposed contours, and spot elevations around buildings. It shall also demonstrate adequate drainage
from the site, no increased flow onto adjacent properties, and off-site drainage improvements (public or
private), if required.
2. Schedule a pre-construction meeting with Town staff at least two business days prior to start of construction.
3. Prior to beginning any construction activities, install Construction Entrance and the following Erosion and
Sediment Control measures as shown on plot plan and/or specified by Town staff during pre-construction
meeting:
4. During construction, the adjacent road, properties, existing drainage structures, streams, etc., shall be protected
from erosion or sediment deposition from this project.
5. All denuded areas on the lot shall be stabilized within 7 days of final grading with permanent vegetation or a
protective ground cover suitable for the time of year.
6. Submit Land Disturbing Permit bond with the Department of Public Works as follows (select one):
$1,200 (up to 10,000 sq. ft. disturbed area)
$2,400 (over 10,000 sq. ft. disturbed area)
B. Water Quality Plan: Permittee shall adhere to performance standards stated in the Town of Ashland Water Quality
Protection Ordinance, which represent minimum practices necessary to protect the quality of water resources from
non-point source pollution resulting from construction projects. These performance standards are as follows:
1. The land disturbance shall be limited to the construction footprint.
2. A wetland assessment shall be completed, and a report submitted to the Town unless the Director of Public Works
(or designee) approves a waiver. If wetlands are identified, they shall be delineated and flagged. Wetland permits
shall be obtained if required from appropriate state or federal agencies. Select one for waiver request:
An explanation and information are attached to support waiver
This is part of an approved subdivision where wetlands have been addressed.
Name of Subdivision: ________________________________________________
3. Ingress and egress during construction shall be limited to one access point.
4. Indigenous vegetation shall be preserved to the maximum extent possible. Existing, healthy trees over 6
inches in diameter shall be preserved outside of the limits of disturbance.
5. Clearing shall be allowed only to provide necessary access, drainage, and utilities as approved by the Town
Manager or designee.
6. Impervious cover shall be minimized to promote the infiltration of storm water.
7. Disposition
of natural waters and storm waters on and off the site shall be provided so as not to have a detrimental
effect on the property of others or public lands and conform to the standards of the Town of Ashland Water
Quality Protection Ordinance.
Page 2 of 2
Rev 12/2020
8. Additional measures specified by the Town of Ashland:
C. Stormwater Management Plan: Permittee shall adhere to the below requirements to ensure compliance with the
applicable post-construction stormwater management provisions of the Town of Ashland Virginia Stormwater
Management Program (VSMP) Ordinance and all State and Federal Regulations.
1. A copy of this signed and dated agreement shall be maintained on-site during construction. It must be included
in the on-site Stormwater Pollution Prevention Plan (SWPPP) if a Construction General Permit (VAR10) was
issued for project.
2. Submit a TOA Stormwater Fee Form with applicable fee.
3. Post-construction runoff from the property shall be minimized to the maximum extent practicable and shall be
controlled to prevent flooding or erosion damage from occurring on adjacent or downstream properties. These
practices shall be followed to meet this requirement:
a. Direct runoff from rooftops as non-erosive sheet flow to well-vegetated areas on the property to the
maximum extent practicable,
b. Direct runoff from on-lot impervious surfaces (e.g., driveways, parking areas, sidewalks) as non-erosive
sheet flow to well-vegetated areas on the property to the maximum extent practicable, and
c. Direct runoff from lawns as non-erosive sheet flow to undisturbed naturally vegetated areas on the property
to the maximum extent practicable.
Failure to comply with any of the requirements above may result in the revocation of this Agreement and may require
the submittal of a project-specific Erosion and Sediment Control Plan, Water Quality Plan and/or Stormwater
Management Plan in accordance with the Town of Ashland ordinances. In addition, failure to comply with these
requirements within three (3) working days following notice by Town of Ashland staff may result in citation for violation
of the Town of Ashland’s Erosion and Sediment Control Ordinance, Water Quality Protection Ordinance and/or
Stormwater Management Ordinance.
I certify under penalty of law that I have read and understand these requirements:
Signed: Date:
Printed Name:
Select One:
Property Owner
Responsible Land Disturber (RLD Number _______________)
TOWN OF ASHLAND
Approved:
Title: _____Director of Public Works
Land Disturbing Permit Number: _____________
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LAND DISTURBING PERMIT (Town of Ashland, VA)

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Completed 14 January 2021

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