Soil Erosion and Sediment Control Permit Application

Applicant Information
Landowner Name*

First NameLast Name
Mailing Address*

Street Address

Apt/Unit

City/Township/VillageState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Designated Agent

(If different from landowner. MUST SUBMIT SIGNED DESIGNATED AGENT STATEMENT)
Name

First NameLast Name
Address

Street Address

Business

City/Township/VillageState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com

Site Location

Site location information is located on your Property Tax paper work under the Description header.
Address*

Street Address

Apt/Unit

City/Township/VillageState

Postal / Zip Code
Parcel Tax Identification #*
Section*
Town (T)*
Range (R)*
Subdivision
Lot Number*

Soil Erosion and Sedimentation Control Plan
Plan Preparer*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Parties Responsible for Earth Change
On-Site Individual Responsible for Overseeing Earth Change *

First NameLast Name
Address*

Street Address

Business/Organization

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com

Additional Documents
Permits submitted without the appropriate documents will not be accepted.

Note: Designated agent forms are required if the applicant is anyone other than landowner. Landowner AND designated agent must sign form. Permits without applicable designated agent statement will not be accepted.
SESC Site Plan*

Sketch, aerial view and/or maps
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Check off items included on drawing, site plan or constrcution schedule.*

Scaled down plan drawing with listed exact distances or dimensions. Scale should be no more than 200 feet per inch.Distance from earth change activity to nearest body of water (in feet)Land features (show hills, ditches, etc.)Contour intervals and slope directions with arrows (unless site is completely flat)Full physical limits of proposed earth work and grading changesDescription and location of all existing proposed drainage facilities.Description and location of all exisiting and proposed drainage facilities (culverts, drainage tiles, etc.)Description and location for installing and removing all proposed temporary SESC measures (silt fence, mulch blanket, etc.)Description and location of all proposed permanent SESC measures.
Plot Plan (aerial view)*

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Submit additional files, if applicable.

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Directions to Site (from Conservation District)

By signing below, you agree to grant County Enforcing Agency representatives access to the project site to ensure compliance with Part 91 regulations.
Landowner or Designated Agent*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

Applicant Information