APPLICATION NUMBER: __________
WHITE COUNTY APPLICATION FOR FLOODPLAIN DEVELOPMENT PERMIT
SECTION 1:     General Provisions (APPLICANT to read and sign)
1	Permit will not be granted unless all planned construction/development, including any work
	already begun, is compliant with the applicable requirements stated herein.
2	Work at the site prior to issuance of conditional permit is solely at the risk of the applicant.
3	The permit may be revoked if any false statements are made herein.
4	The permit will expire if no work is commenced within six months of issuance.
5	Applicant is hereby informed that other permits may be required to fulfill local, state, and
	regulatory requirements.
6	Frequently, base flood elevation data must be determined for construction and/or development
	in a special flood hazard area.   Applicant agrees to obtain the services of a registered engineer
	or land surveyor for purposes of calculating and certifying any required base flood elevations.
7	Applicant hereby gives consent to the White County Floodplain Administrator or his/her
	representative to make reasonable inspections required to verify compliance.
8	APPLICANT CERTIFIES THAT ALL STATEMENTS HEREIN AND IN ATTACHMENTS TO THIS APPLICATION ARE, TO THE BEST OF MY KNOWLEDGE, TRUE AND ACCURATE.
(APPLICANT'S SIGNATURE)  _____________________________________  DATE: ____________
SECTION 2:  Proposed Development  (To be completed by APPLICANT)
NAME			ADDRESS				TELEPHONE
_______________________________________________________________________________
APPLICANT
_______________________________________________________________________________
BUILDER
_______________________________________________________________________________
ENGINEER / SURVEYOR
PROJECT LOCATION:
Provide enough information to easily identify the project location.  Provide the street address and
distance to nearest intersecting road or well-known landmark.  Attach legal description of property.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
APPLICATION NUMBER: __________
SECTION 2 (continued):  Proposed Development  (To be completed by APPLICANT)
DESCRIPTION OF WORK (CHECK ALL APPLICABLE BOXES):
A.  STRUCTURAL DEVELOPMENT
	ACTIVITY				STRUCTURE TYPE:
		New Structure				Residential (1 - 4 Family)
		Addition				Residential (More than 4 Family)
		Alteration				Non-residential
		Relocation				(Floodproofing?              Yes)
		Demolition			Combined Use (Residential & Commercial)
		Replacement			Manufactured (Mobile) Home
					(In Manufactured Home Park?         Yes)
B.  OTHER DEVELOPMENT ACTIVITIES
		Clearing	Fill		Mining	Drilling		Grading
		Excavation (Except for structural development checked above)
		Watercourse Alteration (Including Dredging and Channel Modifications)
		Drainage Improvements (Including Culvert Work)
		Road, Street or Bridge Construction
		Subdivision (New or Expansion)
		Individual Water or Sewer System
		Other (Please specify) __________________________________________
SECTION 3:  Floodplain Determination  (To be completed by Administrator)
The proposed development is located on FIRM Panel No. ___________________ Dated _________
The Proposed Development:
	Is not located in a Special Flood Hazard Area (SFHA).
	(NO FLOODPLAIN DEVELOPMENT PERMIT IS REQUIRED.)
	Is partially located in the SFHA (Zone A).
	Is located in the SFHA (Zone A).
	Is located in the floodway.
Base Flood Elevation (BFE) at the site
	is: _______________ FT. NGVD (MSL)
	must be determined and certified by registered surveyor or engineer.
	is not required for this project.
	Application for floodplain development permit is denied.
	Application for permit is conditionally approved.  See Section 3 (current section) and
	and Section 4 for additional information needed before permit can be issued.
Signed	Debra Lang				by	________________________
	White County Floodplain Administrator					William R. Teague CFM, Deputy
APPLICATION NUMBER: __________
SECTION 4:  Additional Information Required  (To be completed by Administrator)
Applicant must submit the documents checked below before the application can be processed.
	A site plan showing the location of all existing structures, water bodies, adjacent roads,
	and proposed development.
	Development plans, drawn to scale, and specifications, including where applicable:
	details for anchoring structures, proposed elevation of lowest floor, types of water
	resistant materials used below the first floor, details of floodproofing of utilities below the
	first floor, and details of enclosures below the first floor.
	Also, _________________________________________________________________
	______________________________________________________________________
	Attach certification by registered surveyor or engineer: lowest finished floor elevation of
	any existing and/or proposed residential structures ______________ FT. NGVD (MSL)
	Subdivision plat showing base flood elevation contour(s).
	Plans showing the extent of watercourse relocation and/or landform alterations.
	Change in water elevation (in feet).
	Top of new compacted fill elevation ______________ FT. NGVD (MSL)
	Floodproofing protection level (non-residential only) __________ FT. NGVD (MSL)
	Attach certification from registered engineer or achitect for floodproofed structures.
	Other ___________________________________________________________________
	________________________________________________________________________
	________________________________________________________________________
SECTION 5:  PERMIT DETERMINATION  (To be completed by Administrator)
The proposed activity:
		A.	Is
		B.	Is not
in conformance with provisions of the White County Flood Damage Prevention Ordinance #97-11.
The permit is issued subject to the conditions attached to and made part of this permit.
Signed	DEBRA LANG, WHITE COUNTY FLOODPLAIN ADMINISTRATOR
by ____________________________________________       Date: _________________
	William R. Teague CFM
	Deputy
If Box A is checked, Administrator may issue Development Permit.
If Box B is checked, Administrator will provide a written summary of deficiencies.  Applicant may
revise and resubmit application to Administrator.
APPLICATION NUMBER: __________
SECTION 6:  (To be submitted by APPLICANT before Certificate of Compliance is issued)
The following information must be provided for project structures.  This section must be completed
by a registered professional engineer or a licensed land surveyor (or attach a certification to this
application).  Complete 1 below for residential structures.  Complete 1 and/or 2 for non-residential
structures.
1	Actual (As-Built) Elevation of the top of the lowest floor is: __________ FT. NGVD (MSL)
2	Actual (As-Built) Elevation of floodproofing protection is: __________ FT. NGVD (MSL)
Certified by:  __________________________________    Date: ____________________
		Engineer or Land Surveyor
SECTION 7:  CERTIFICATE OF COMPLIANCE (To be completed by local administrator)
Certificate of Compliance issued: DATE: _________________ BY: ______________________