PERMIT APPLICATION FOR
GRADING
PROJECT ADDRESS _________________________________________________________________________________________________________________
LAND OWNER _______________________________________________________________________________________________________________________
ADDRESS __________________________________________________________________________________ PHONE _________________________________
CITY _____________________________________________ STATE ___________________________________________ ZIP CODE _____________________
DESIGNATED AGENT ________________________________________________________________________________________________________________
ADDRESS __________________________________________________________________________________ PHONE _________________________________
CITY _____________________________________________ STATE ___________________________________________ ZIP CODE _____________________
DATE OF PROJECT START _________________________________ DATE TO BE COMPLETED ___________________________________________
PROJECT TYPE:
_____RESIDENTIAL _____MULTI-FAMILY _____COMMERCIAL _____INDUSTRIAL _____LAND BALANCING
PROJECT DESCRIPTION ____________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
______________________________________________________________ SIZE OF EARTH CHANGE____________________________________________
MUST INCLUDE 2 COMPLETE SETS OF TOPOGRAPHICAL PLANS DRAWN AT A SCALE OF NOT LESS
THAN ONE INCH EQUALS 50 FEET AND SHALL SHOW EXISTING AND PROPOSED GRADES AND
TOPOGRAPHIC FEATURES
PLAN PREPARER’S NAME_____________________________________________________________ PHONE ______________________________________
PERFORMANCE DEPOSIT AMOUNT REQUIRED $______________________________________________
_____CASH _____CERTIFIED CHECK _____IRREVOCABLE LETTER OF CREDIT _____SURETY BOND
NAME OF SURETY COMPANY _____________________________________________________________ PHONE __________________________________
ADDRESS _________________________________________________ CITY/ST/ZIP ____________________________________________________________
ENGINEERING APPROVAL_________________________________________________ DATE_________________________
I (we) affirm that the above information is accurate and that I (we) will conduct the above described earth change in accordance
with Part 91, Soil Erosion and Sedimentation Control of the Natural Resources and Environmental Protection Act, 1994 PAA
451, as amended, applicable local ordinances and the documents accompanying this application.
LAND OWNER’S SIGNATURE __________________________________________________________________ DATE _______________________________
LAND OWNER’S NAME (PRINTED) ___________________________________________________________________________________________________
DESIGNATED AGENT’S SIGNATURE * _________________________________________________________ DATE _______________________________
DISIGNATED AGENT’S PRINTED NAME _____________________________________________________________________________________________
* AGENT MUST HAVE WRITTEN STATEMENT FROM LANDOWNER AUTHORIZING HIM/HER TO SECURE A PERMIT
