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Land Disturbance and Grading Permit Application (Applicable to sites 1 acre, part of a common plan of development or adjacent to water bodies/sensitive lands) Please print and return completed form to Millcreek offices (address above) for review and approval. • Fee calculated at $200 + $50 per acre (rounded up to nearest whole number). • All land disturbance activities must comply with Millcreek Municipal Code 17.22.040 • Permit not valid after 18 months from Date Issued above. PROPERTY INFORMATION Address Parcel Number Subdivision Lot Number CONTACT INFORMATION APPLICANT Name Address Phone Email OWNER Name Address Phone Email CONTRACTOR Name Address License No. Phone Email DESCRIPTION OF LAND DISTURBANCE WORK OR GRADING ACTIVITY Type of Work: Disturbed Area: Material to be moved/removed (yds): UPDES Number (if applicable): Anticipated Start Date: Proposed Completion Date : PLEASE CHECK ALL THAT APPLY REQUIRED SUBMITTALS: ☐ General vicinity map of the proposed site ☐ Legal description of property ☐ Dust control measures ☐ Erosion Control Plan ☐ plan (as applicable) ☐ Evidence of UPDES permit (as applicable) ☐ Utah State Notice of Intent (NOI) CONDITIONAL SUBMITTALS: ☐ Approved Grading Plan for grade change greater than 12 -inches ☐ Temporary vegetation protection plan ☐ Re-vegetation plan ☐ Certified Traffic Control Plan, including haul route ☐ Completion Bond ☐ Verification of approval for all applicable State and Federal environmental permits For questions regarding this application contact the Millcreek Storm Water Engineer, Dan Drumiler, at [PHONE REDACTED] A separate UPDES Permit must be obtained from the state and a copy submitted with this application prior to issuance of Land Disturbance Permit. Parcel Number may be obtained from the Salt Lake County Assessors’ web page. Millcreek Engineering 3330 South 1300 East Millcreek, Utah 84106 (801) 214-2700 millcreek.us Permit No. Permit Fee $ Date Issued Termination Date FEES ARE NON-REFUNDABLE