Floodplain Development Application – Form 0500 Fill This Form Out Online or Scroll to the Bottom of this Page for a Printable Copy Floodplain Development Application - Form 0500 FloodplainDevelopment Application - Form0500 Department of Planning and Zoning P.O.Box217, Independence, VA 24348 Phone:276-773-2471 Fax-276-773-3673 www.graysoncountyva.govName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Name of Property Owner (if different) First Last Tax Map Number* Acreage of Parcel* 911 Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Proposed Use/ Activity*Floodplain District* Floodplain Elevation (ft)* A- All uses, activities, and development occurring within any floodplain district shall be undertaken only upon the issuance of a zoning permit for development in the floodplain. It is the responsibility of the property owner to determine whether their proposed development is in a designated floodplain, as determined by the Federal Emergency Management Agency, Federal Insurance Administration and affiliated flood insurance/flood plain designation maps. The Grayson County Flood Plain Ordinance shall dictate the administration of Flood Plain Management in Grayson County. The Ordinance is available for review in the Building/Zoning Department. Property owners should reference the ordinance prior to any plans for activities or development in the floodplain. Please sign below if you understand your responsibilities as it relates to floodplain development in Grayson County.Signature* Date* MM slash DD slash YYYY B - Under no circumstances shall any use, activity, and/or development adversely affect thecapacity of the channels, floodways of any watercourse, drainage ditch, or any other drainagefacility or system. Encroachments, including fill, new construction, improvements or other development are prohibited unless certification (with supporting technical data) by a professional engineer is provided demonstrating that encroachments shall not result in any increase in flood levels during occurrence of the base flood. Please sign below if you will not adversely affect the floodway or drainage within the proposed area of development Or Proceed to Section CSignature Date MM slash DD slash YYYY C- If proposed development/activities will increase the water surface elevation; permission must be obtained by the Federal Emergency Management Agency. Please sign here if permission has been obtainedSignature Date MM slash DD slash YYYY D. Prior to any proposed alteration or relocation of any channels or of any watercourse, stream, ect., within this jurisdiction a permit shall be obtained from the U.S. Corps of Engineers, The Virginia Department of Environmental Quality, and the Virginia Marine Resources Commission (a joint permit application may be available) Furthermore, notification of the proposal shall be given by the applicant to all affected adjacent jurisdictions, The Department of Conservation and Recreation Division ofDam Safety and Floodplain Management and the Federal Insurance Administration. If the proposedactivity/development will alter or relocate channels or watercourses, please sign here to confirm that you have notified each of the agencies listed above:Signature Date MM slash DD slash YYYY E. Any structure or additions to structures located in a designated floodplain area must adhere to therequirements of the Grayson County Building Department for construction in a flood prone area. Prior to the issuance of a zoning or building permit for construction, applicants shall schedule aconsultation with the Building Official and demonstrate that they will build in conformance with flood prone construction. Please sign here if you understand this requirement:Signature Date MM slash DD slash YYYY Building Official RequirementsF. Any grading or other disturbance of soil in the floodplain may not occur until a review has determined that the project can meet the Floodplain Ordinance. Where grading or disturbance will exceed 10,000 square feet a separate Erosion & Sediment Control Permit must be obtained. Disturbed areas less than 10,000 square feet will require stabilization and reseeding. Sign here if you understand this requirement:Signature* Date* MM slash DD slash YYYY I certify that all information listed on this application is true and correct to the best of my belief/knowledge.By signing this application I grant permission for an agent of the Building/Zoning Department to visit my site as it applies to this application.Signature* Date* MM slash DD slash YYYY Download (PDF, 37KB)
