Date of Issuance


Good for one year from date of issuance.
City of Goodlettsville
LAND DISTURBANCE PERMIT
 Permit No.
Owner Name & Phone Number


 Project Name


  
Owner Address


 Subdivision/Section


 Lot No.
Contractor Name & Phone Number



 Control Map & Parcel Number



 TDEC NPDES #
Contractor Address



 Starting and Completion Dates



  
Land Area Disturbed



 Property Address



 Permit Fee

This permit must be applied for at The City of Goodlettsville Public Works Department, 215 Cartwright Street, Goodlettsville, Tennessee.  (615) 859-2740.

The City of Goodlettsville, Tennessee hereby grants permission to commence with grading work.  Grading work must commence within 60 days of issuance or grading permit will be void.

The permit is good for one year from date of issue - after that date, you must contact this office for renewal.
Applicant must have an approved Storm Water Pollution Prevention Plan (SWPPP) and an Erosion Prevention and Sediment Control Plan (EP & SC) for this site before grading work can commence.

Notice of work:  The contractor shall provide the City of Goodlettsville Public Works Department (615) 859-2740 with a ten (10) day notice prior to any grading work.  Grading shall conform to lines and grades as shown on the approved drawing and shall be in accordance with the specifications as approved by the City of Goodlettsville and its Stormwater Management Ordinance and Best Management Practice Manual.

Where applicable, work shall also conform to the requirements as for construction done near or in a stream potentially effected by the project set forth in the Aquatic Resource Alternation Permit (ARAP) as issued by the Natural Resource Section of the Tennessee Department of Environment and Conservation on _____________ and the Department of Army permit issued by the Corps of Engineers on ____________ for their work in or near delineated wetlands.  No work shall commence within a TVA easement until TVA has granted permission and written verification is provided to the City of Goodlettsville.  The contractor and/or developer shall be responsible for obtaining all permits required by agencies and/or governmental entries having jurisdiction.

Erosion control devices, as shown on the Erosion Prevention & Sediment Control Plan (enclose plan with this Land Disturbance Permit) shall be in place prior to any grading, clearing and/or any other construction activity.  These devices shall be maintained throughout the construction period; generally considered to be through the completion of restoration.  A copy of your ER & SC plan, along with an inspection checklist and Stormwater Permit, must be at the project site at all times.  The inspection checklist shall have a record of dates EP & SC devices are inspected and any correction action taken or major observations.

All EP & SC devices are to remain in place until the site has been stabilized and a good stand of grass has been established.

Erosion prevention and sediment controls must be inspected at least twice every calendar week and at least 72 hours apart.  Inspections are to be documented and kept with the SWPPP.

The project is subject to inspection by the City of Goodlettsville at any time and items found deficient shall be immediately corrected.  The City may stop construction on properties or administer other enforcement action as defined by Goodlettsville's Stormwater Management Ordinance including Civil Penalties of $50 to $5,000 per day of violation.


Pre-Construction checklist:
Please initial that these have been accomplished before construction begins:

_______ Stormwater Management Plan and Erosion Prevention Sediment Control Plan accompany this permit.

_______ Silt fence or other sediment barriers will be installed properly along topographical contours downslope of the area to be disturbed prior to any grading, clearing and/or any other construction activity.  Excavated topsoil to be reused must be stockpiled and encircled with silt fencing.

_______ This site shall contain a temporary stone construction entrance that conforms to the City of Goodlettsville's Stormwater Ordinance and Best Management Practice Manual within 24 hours of grading commencement or the permit will be revoked.  The stone shall be 2-3 inches in diameter and shall be kept clean by adding stone as needed.  It shall be at least 6 inches deep and underlain with filter fabric and 20 feet wide.

_______ Where applicable, approved inlet protections for nearby storm sewer curb and drop inlets have been installed.

_______ Where applicable, existing vegetation and buffer will be maintained and temporary cover crops will be used.

_______ Offsite material storage and/or borrow areas (also including overburden and stockpiles of dirt, etc.) used for this project are considered part of the project and are hereby governed by this permit.


The following Erosion Prevention and Sediment Control (EP&SC) Best Management Practices (BMPs) will be performed until Bond is released:

  • Vegetative buffers or other protection must be provided along streams, rivers and ponds to avoid erosion of banks.
  • Stabilization measures must be performed within seven (7) days in portions of the site where construction activities have temporarily or permanently ceased, and within fifteen (15) days after final grading.
  • All trees designated to remain, must be protected.  Heavy equipment should not be operated or stored, or materials handled or stored, within the drop line of trees.
  • Sediment must be removed from sediment barriers, ponds and other sediment controls when design capacity has been reduced by 33%.
  • Sediment that has escaped the construction site and has collected in the street or drainage structures must immediately be physically removed.
  • Building and waste materials, and non-stormwater discharges such as concrete, paint wash water or machinery leakage or spillage, must be managed to prevent them from entering the stormwater system, ground water or nearby water body.
  • BMPs must be inspected by a qualified person who has taken an approved erosion and sedimentation course.
Issuance of this Land Disturbance Permit does not exempt you from complying with any provision of the City of Goodlettsville's Stormwater Management Ordinance that applies.

All correspondence must reference the above-noted Permit Number.


I certify, under penalty of law, that I have reviewed this document and understand the erosion prevention and sediment control requirements herein.  I agree to implement and follow the provisions of the Land Disturbance Permit for the construction site.  I understand that these requirements will be inspected and enforced by the City of Goodlettsville and failure to comply may result in the issuance of a "Stop work order" and/or other penalties until compliance is accomplished.  The undersigned will be responsible for complying with this permit and any provision of the Goodlettsville Stormwater Management Ordinance that applies.

Printed Name


 Signature


 Date

 
 Permit issued by:

Printed Name


 Signature


 Date



LAND DISTURBANCE PERMIT
INSTRUCTIONS


This permit must be applied for at the City of Goodlettsville Public Works Department office which is located at 215 Cartwright Street, Goodlettsville, TN.

Purpose of this form: 
To eliminate any non-allowable discharges to Goodlettsville's Municipal Separate Storm Sewer System (MS4) that impacts water quality.

Completing this form:
Type or print clearly, using ink - no marker or pencil.  Initial each blank item signifying that you have read these sections and will comply with them.  Submitting this Land Disturbance Permit does not exempt you from complying with all aspects of the City of Goodlettsville's Stormwater Management Ordinance.  This form does not exempt you from obtaining any other state, local or federal required permits or documents.

Who must submit a Land Disturbance Permit form?
Anyone that is disturbing more than one acre of land use.

No site development permit is required for the following activities:
  • Any emergency activity that is immediately necessary for the protection of life, property or natural resources.
  • Agricultural land management activities (except where the clearing of the land, forest or other agriculture activity results in activities other than further agriculture or forest use).
  • Additions or modifications to existing detached single-family dwellings.
  • Developments that do not disturb more than one acre of land use.  This exemption may not be applied for contiguous properties that may have been subdivided and/or are attributed to multiple separate owners.  This exemption does not apply to any discharge of sediment or other form of water pollution that may leave a small site.
Other permits:
An ARAP permit may be required.  If your work will disturb or cause alterations of a stream or wetland, you must obtain an appropriate Aquatic Resource Alteration Permit (ARAP) before you will receive a City of Goodlettsville Land Disturbance Permit. 

If you have a question about the ARAP program or permits, contact your local Tennessee Department of Environment and Conservation Environmental Assistance Center.

If you are disturbing more than one (1) acre, you will also need an NPDES Permit from TDEC. A copy of this permit must be supplied to us before a City of Goodlettsville Land Disturbance Permit will be issued.