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PERMIT INFORMATION®
Developer’s Name: __________________________________________________________________________
Developer’s Contact Name: _______________________________________ Title: _ ____________________
Email: ____________________________________________________________ Phone: __________________
Complete Address: __________________________________________________________________________
Employer ID #: __________________________ Phone: _________________________ Fax: ________________
Property Owner: ____________________________________________________________________________
Contact Name: __________________________________________________ Title: _______________________
Email: _____________________________________________________________ Phone: _________________
Employer ID or SS #: ________________________ Phone: ________________________ Fax: ______________
Project Name: ____________________________ Parcel#: __________________________ Acreage: _________
Project Address: ____________________________________________________________________________
Project Type: Residential __ Commercial __ Estimated Start Date: __________ Completion Date: _______________
Description: ________________________________________________________________________________
Authorized Signatory for SWPPP (Manager or above): _______________________________________________
Site Supervisor: ________________________________________________ Title: ________________________
Email: __________________________________________________________ Phone: ____________________
Dust Class Certification #: ___________________________________ Expiration Date: _____________________
Person responsible (on job site) for dust control: _____________________ And SWPP: _____________________
Water Source (circle all that apply): Water Truck - Hydrant - Jones Valve – Stand Tank – other ________________
Will there be offsite work? Y __ N __ Approved Plan # for offsite work: __________________________________
Description of Work Performed: Include Demo, Blasting, Crushing and Owners Designee (name, address, phone and email) __________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________________
Please include a copy of the soil report and a set of mini plans (10X17), for the preparation of the SWPPP.
Revised 05/21/2020
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