Fillable Land Disturbance Permit Application (Boone County, Missouri)

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Land Disturbance Permit Application (Boone County, Missouri)

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Resource Management
Boone County, Missouri
801 E. Walnut, Room 315
Columbia, Missouri 65201
573-886-4330
Land Disturbance Permit Application
A land disturbance permit is required prior to land clearing activities equal to or greater than one-acre or in close proximity of an
environmentally sensitive area. The applicant can request a Land Disturbance permit through the Boone County Resource Management
Office. N
OTE
:
When properly validated, this form constitutes a permit.
Please attach additional sheets as required to fulfill application
requirements. NO BUILDING INSPECTIONS MAY TAKE PLACE UNTIL THE LAND DISTURBANCE PERMIT HAS BEEN
ISSUED.
J
OB
/S
ITE
I
NFORMATION
O
WNER
: ________________________________________________________________________
Name Address Phone
______________________________________________________________________________________
Email Address Mobile Phone
P
ROJECT
N
AME
:
________________________________________________________________________
P
ROJECT
A
DDRESS
:
________________________________________________________________
P
ARCEL
N
UMBER
: ______________________________________________________________________
P
ROJECT
D
ESCRIPTION
: _____________________________________________________________
T
OTAL
S
ITE
A
REA
: __________________________ T
OTAL
D
ISTURBED
A
REA
______________
D
EVELOPER
: ____________________________________________________________________
Name Address Phone
_____________________________________________________________________________________
Email Address Mobile Phone
C
ONTRACTOR
: ___________________________________________________________________
Name Address Phone
______________________________________________________________________________________
Email Address Mobile Phone
T
YPE OF
C
ONSTRUCTION
A
CTIVITY
___
C
LEARING
&
G
RADING
O
NLY
___
P
LANNED
D
EVELOPMENT
___
R
OAD
C
ONSTRUCTION
___
C
OMMERCIAL
___
E
NVIRONMENTALLY SENSITIVE AREA
___
S
INGLE
F
AMILY
/R
ESIDENTIAL
O
WNERS
C
ERTIFICATION
The undersigned owner certifies that he/she is responsible for complying with the Boone County Stormwater Ordinance
and for complying with the county-approved erosion and sediment control plan for this project. Boone County
employees may enter the property for the purpose of inspecting and or completing erosion and sediment control
measures. I understand that a final inspection by the Resource Management Inspectors must be requested, and all land
disturbances found to be in compliance, in order for the performance bond to be released.
Signature of Land owner Printed Name and Title of Landowner Date
For office use only
Permit number:______________
Date Received:______________
Related permits:_____________
Issue date:__________________
Revised 7/15/12 2
C
ONTRACTORS
C
ERTIFICATION
I herby certify that the proposed site will be built according to the stamped approved Construction Plans. I
further understand that any field modifications will be documented in writing, and delivered to the Boone
County Inspector. Major modifications require a resubmittal of the plans with the changes indicated.
I herby certify that all erosion prevention and sediment control practices will be inspected weekly and within
24 hours of a rain event causing runoff. The permittee or contractor will maintain written records of such
inspections and repairs. These records must be kept on the job site or in the office of the responsible person
and be available for review at any time by an individual from the Boone County Resource Management Staff.
Signature of Contractor Printed Name and Title of Contractor Date
Inspector Comments: ____________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
F
OR OFFICE USE ONLY
Permit fee: $___________ Date Paid: ____/____/____
Copy of Bond on file with the County: (yes/no/waived) Amount of Bond: $___________
Copy of MDNR permit in file? (Yes/No/Not applicable) MORA: ____________________
Construction plan/Erosion & Sediment Plan approval date:
Pre-con meeting date: ____/____/____ Construction Start date: ____/____/____
Work days/months estimated to complete project: ___________________
Application approved /denied by: _________________ Date: ____/____/____
Permit Expires: ____/____/____
Permission is hereby given to proceed with construction as shown on the approved plans and in compliance with the
Ordinances of Boone County:
Signature of Approving Authority Date:
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Land Disturbance Permit Application (Boone County, Missouri)

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Completed 20 August 2020

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