Application for Land Disturbance Permit

TANEY COUNTY PLANNING & ZONING
PO Box 383 / 207 David Street
Forsyth, Missouri 65653
417-546-7225 or 417-546-7226
Email: cody.stice@taneycountymo.gov

APPLICATION FOR LAND DISTURBANCE PERMIT

NAME OF APPLICANT:

ADDRESS: CITY/STATE/ZIP__________________________________

TELEPHONE: SEC____________TWP_____________RNG______________

PROPERTY #: ____________________________________________________________________________

NAME OF PROPERTY OWNER:

LOCATION:

PROPERTY ACCESS (Street Name):

NUMBER OF ACRES TO BE DISTURBED____________________________________________________

DOES THE PROPERTY LIE IN THE 100-YEAR FLOODPLAIN? (CIRCLE ONE) YES______NO______

THE FOLLOWING SUBMITTALS MUST BE INCLUDED:

 $75.00 APPLICATION FEE (Check or Cash)

 DESCRIPTION OF WORK TO BE DONE IN YOUR OWN WORDS.

 PROOF OF OWNERSHIP

 IF AREA OF LAND DISTURBANCE EQUALS 1 ACRE OR MORE, PERMIT FROM THE MISSOURI
DEPARTMENT OF NATURAL RESOURCES REQUIRED

 LAND DISTURBANCE PLAN AND EROSION AND SEDIMENT CONTROL PLAN

 LAND DISTURBANCE BOND

LANDGRADING PERMIT#___________________BOND AMOUNT$______________ Check #___________

READ BEFORE SIGNING: In signing this application, I understand that if the information provided here is not true, my permit will
Be revoked. I understand and agree to abide by the requirements of the Taney County Commission and the
Taney County Planning Commission. I agree to all inspections on my property necessary to secure compliance
With all county codes relevant to this application. Property owner is responsible to adhere to all private
Restrictions and easements.

_________________________________________________ DATE____________________________________
PROPERTY OWNERS SIGNATURE