Full Text
Page 1 of 3 Soil Erosion & Sedimentation Control Permit Application City of Midland Building Department: 333 West Ellsworth Street: Midland, Michigan 48640: [PHONE REDACTED]: Fax [PHONE REDACTED]: www.midland-mi.org Project Information: Project Name: Site Address: Parcel Number: Description of Work: Total Parcel Size: Total Disturbed Area*: *If earth change area is 5 acres or greater, a NPDES (National Pollution Discharge Elimination System) permit must be obtained from MDEQ. Applicant Information: Landowner(s): Company Name: Address: City: State: Zip Code: Phone Number: Work: Cell: Fax: E-mail Address: Designated Agent** Information: (check one) Architect/Engineer______ Contractor______ Other Name: Company Name: Address: City: State: Zip Code: Phone Number: Cell: Fax: E-mail Address: Designated Agent must have written statement from landowner authorizing him/her to secure a permit in landowner’s name. On- Site Project Contact: Name: Company Name: Address: City: State: Zip Code: Phone Number: Cell: Fax: E-mail Address: Certified Storm Water Operator: Name: Cert. Number: Exp. Date I (We) affirm that the information in this application is accurate and that I (we) will conduct the above described earth change in accordance with Part 91, Soil Erosion and Sedimentation Control, of the Natural Resource and Environmental Protection Act, Act 451 of the Public Acts of 1994, as amended, it’s corresponding rules, applicable local ordinances, and the documents accompanying this application. I acknowledge that I have read and will comply with the general conditions and responsibilities as outlined in the application. This application serves as written consent for the City of Midland to enter onto this site for the purpose of inspections. This permit does not exempt permit holder from obtaining other permits issued by State or Local agencies. (Landowners Signature) (Print Name) (Date) (Authorized Agent Signature) (Print Name) (Date) Please complete reverse side SIGN SIGN ---PAGE BREAK--- Page 2 of 3 Soil Erosion & Sedimentation Control Permit Application Project Details: Type of Disturbance: (please check all that apply) Residential: Commercial/Industrial: Gravel/Sand Mining Pit: New Residential Subdivision: Will fill material be brought to site:______How many Cu Yds? Type of fill Does project require a MDEQ Permit: If yes, Please provide permit number: Please attach permit for Part 31(Floodplain Occupancy Authority, Part 301 (Inland Lakes and Streams), and/or Part 303 (Wetland Protection) Name of closest Lake, Stream or Distance from: Project Start Date: Expected Completion Date: Please fill in Construction Sequence Schedule: Construction Sequence Schedule Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Soil Erosion Control Measures Install Stone Access Drive In Place Land Clearing Fill and Site Balance Excavation of Building Site Completion of Earth Changes Seed and Mulch as Required Area Stabilized Temporary Measures Removed Soil Erosion and Sedimentation Control Plan Details: Plan Preparer’s Name: Number: Estimated Cost of All Temporary and Permanent Control Measures: Items Required to process permit: 1) This application completed in its entirety. 2) Site/ SESC Plans showing the following: a. Scaled, (no larger than 200’/inch), location map and address, or legal description, of parcel with north arrow. b. Map showing physical limits of proposed earth change. c. Soils survey or written description of soil types. d. Topographical map, contours or grade shots accurately showing existing and proposed drainage patterns. e. Location of any Lakes, streams, wetlands, drains, etc. f. Location of proposed structures, driveways, ponds, stormwater basins, catches basins…etc. g. Location of stone access drive and all SESC control measures. h. Floodplain information. i. Maintenance schedule and notes for all SESC measures. j. Vicinity map showing project location and adjacent properties within 500 feet of site boundaries. 3) Soil Erosion and Sedimentation Control Permit Fees. All SESC Measures Must be Inspected and Approved before any Earth Change May Begin. FOR OFFICIAL USE ONLY: Site Priority Classification: Level 1: Level 3: Level 2: Level 4: ---PAGE BREAK--- Page 3 of 3 Letter of Authorization City of Midland Building Department: 333 West Ellsworth Street: Midland, Michigan 48640: [PHONE REDACTED]: Fax [PHONE REDACTED]: www.midland-mi.org To Secure a Soil Erosion and Sedimentation Control Permit I, the landowner, of property, parcel address authorize (Print Designated Agent’s Name) to secure a Soil Erosion and Sedimentation Control permit for the earth change on my property. Landowner’s Name: Company Name: Address: City: Zip: Phone Numbers: Home: Cell: Work: E-mail: (Landowners Signature/ Date) (Print Name) Designated Agent’s Name: Company Name: Address: City: State: Zip: Phone Numbers: Home: Cell: Work: E-mail: (Designated Agent’s Signature/ Date) (Print Name) SIGN SIGN