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03/2021 After-the-Fact Permit: 3X the fee ($50 x 3 = $150) Owner Parcel # Mailing Address Permit # City Date Submitted State, Zip 60 Days Day Phone Fee Cell Phone Email Property Address Subdivision Twp Section______ Applicant Applicant Same as Owner Name Address 1 Address 2 City State, Zip Day Phone Email Clay County Planning & Zoning 3510 12th Avenue South, PO Box 280 Moorhead, MN 56561-0280 Tel (218) 299-5005 Application Fee: $50.00 Land Alteration Permit Application ---PAGE BREAK--- 03/2021 1) Project Type: ( ) Vegetation Removal, ( ) Fill Only, ( ) Grading Only, ( ) Both Grading and Fill 2) Water Resource Data: Project is Adjacent to: ( ) Lake, ( ) Stream, ( ) Ditch Present Water Level: Ordinary High Water (OHW) Level Highest Known Water Level: 100-Year Flood Level Datum of Elevation: ( ) Sea Level, ( ) Assumed. NOTE: Any fill below OHW may require DNR permit. 3) Flood Plain Data: Is the site in the Flood Plain? IF YES, fill in the remainder of this section. Is the site in the Floodway? Is the site in the General Flood Plain District? NOTE: A site in the floodway or General Flood Plain District indicates that a problem may exist. A Conditional Use Permit and an Engineering Study will be required in order to determine the impacts on flood elevation and velocity. 4) Project Purpose: ( ) Clear Land, ( ) Road or Driveway, ( ) Fill in Wetland, ( ) Elevate Building Site, ( ) Improve Lawn, ( ) Improve Commercial / Industrial Site, ( ) Other 5) Project Scope: Area of Disturbed Ground in acres or sq feet: Volume of Fill in cy: Closest Distance to OHW in feet: Project Start Date: Project Completion Date: 6) Site Characteristics: Project Soil Type: ( ) Sand, ( ) Gravel, ( ) Clay, ( ) Loam Fill Type: ( ) Sand, ( ) Gravel, ( ) Clay, ( ) Loam, ( ) Black Dirt, ( ) Demo Material, ( ) Other Average Slope of Area: (feet of rise for each 10 feet of horizontal distance) Proposed Erosion Control: ( ) Sod, ( ) Stake-Sod, ( ) Seed Only, ( ) Seed and Mulch, ( ) Mulch Only, ( ) No Control, ( ) Other * Indicate on an attached Sketch Plan the location of the land alteration on the site. To the best of my knowledge, I certify that the information provided on this application and accompanying documents is true and accurate. Applicant signature: Township Office Signature: Planning Director Signature: ---PAGE BREAK--- 03/2021