Erosion and Sediment Control
Tim Carpenter - Erosion & Sediment Control Inspector/Plan Reviewer
Jim Whitten - Building Official/MCP
605-1 Pine Street
Hillsville, VA 24343

LAND-DISTURBING SCREENING FORM

Property Owner Name

* Property Owner Address

* Property Owner Phone #

* Property Owner Email

* Land-disturbance Address

* Purpose of Land-disturbance

* Total amount of expected land-disturbance in square feet

All disturbance associated with the project must be accounted for including driveways, septic tanks, septic tank drainage fields and soil stock piles.

* Name of Property Owner (This serves as a Digital Signature)

(FOR OFFICE USE ONLY)

Requires an Erosion & Sediment Control Plan

Requires an Agreement in lieu of an E&S Plan

Exempt

Checked By

Date

* Indicates Response Required