Application No.  

NOTE: This application shall expire six (6) months from the date of issuance in accordance with Section 6.4(a)(3) of the Jessamine County Zoning Ordinance.

1. Name of Applicant     ___________________________________

   Address      ____________________________________

   Phone       ____________________________________

2. Name of Engineer (if applicable)  ___________________________________

   Address ____________________________________

   Phone       ____________________________________

3. Name of Subdivision (Plat Cabinet/Slide Reference) _______________________
4. Location/Description; note in city or in county:

____________________________________________________________

____________________________________________________________

5. Zoning District      __________________________________
6. Number of Lots/Area of Tract  __________________________________
7. List all proposed grading changes and/or improvements proposed:

____________________________________________________________

____________________________________________________________

____________________________________________________________

8. Describe proposed handling, storage, and replacement of topsoil:

____________________________________________________________

____________________________________________________________

____________________________________________________________

9. Describe proposed handling of off-site rim-off; attach stormwater management plan; is culvert required, describe type and size and anticipated flow:

____________________________________________________________

____________________________________________________________

____________________________________________________________

10. If a retaining wall is required, attach construction details, including, but not limited to height, materials, type of construction:

____________________________________________________________

____________________________________________________________

11. If fill is proposed, attach typical sections and describe fill material and placement of fill:

____________________________________________________________

____________________________________________________________

____________________________________________________________

12. If cut is proposed, attach typical sections and describe handling of excess material:

____________________________________________________________

____________________________________________________________

____________________________________________________________

13. Anticipated Completion Date: _________________________________

Signatures:

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FOR OFFICIAL USE

Date Received  ____________________________

Action by Administrative Officer  ____________________________

If permit rejected, state reason(s)  ____________________________

__________________________  __________________________

Administrative Officer  Date

Completion certified by Administrative Officer

__________________________  __________________________

Administrative Officer  Date

Effective on: 1/1/1901