Ms4 Land Disturbance Permit

SUMNER COUNTY DISCLAIMER MS4 LAND DISTURBANCE PERMIT

A Disclaimer is required by TDEC when the property listed below will not be disturbing one (1) acre or more of land for this project and said property is not part of a larger common plan, development or a platted lot of record.

I/We understand that regardless of the size of the parcel or degree of disturbance, the discharge of sediment beyond the site boundaries, or into creeks or streams is prohibited. To avoid disturbed soil from eroding into waterways and being tracked onto roadways, I agree to:

1. Install a construction entrance with a minimum of 6 inches deep of gravel with a geo-textile underlayment, a minimum of 50 feet in length, and 12 feet wide. Gravel shall be between 1½ -3½ inches in diameter. 2. Install a silt fence where needed that is trenched 4”–6” into the ground and backfilled.

Call 615-451-6097 for Inspection when Items 1 & 2 are completed

Construction Full Address ______

Name of Owner______

Owner Address ______

Telephone # Cell ______Work ______

Signature ______Date ______

Circle: Owner, Agent, Contractor or Land Surveyor

*DRAW SITE PLAN ON REVERSE (Show Driveway & Silt Fence) Also, please provide a “Warranty Deed” with each Application