Soil Erosion and Sediment Control Permit Application

Applicant Information
Landowner Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / 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

Street Address Line 2

CityState / 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.
Section*
Location*
Town*
Range*
Township*
City/Village*
County*
Subdivision
Lot Number*
Parcel Tax Identification #*
Street Address*

Proposed Earth Changes
Project Type*

ResidentialMulti-familyCommercialIndustrialLand BalancingCounty Drain Project(s)
Describe Project*
Size of Earth Change (sq. ft)*
Name of nearest lake, stream or drain*
Distance to project*
Est. Project Start Date*

MonthDayYear
Date
Est. Project End Date*

MonthDayYear
May not exceed one year from start date
This is a construction project located on an area of Number* sqft .

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
Blank document forms available at www.arenacconservationdistrict.com/soil-erosion-and-Sediment-Control

Permits submitted without the required documents 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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Designated Agent Statement (if applicable)

Required if applicant is anyone other than landowner. Landowner AND designated agent must sign form. Permits without applicable designated agent statement will not be accepted.
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Affidavit for Waiver of SESC Permit (if applicable)

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Application for Permit Extension

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Pictures of Site Before Construction

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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

Designated Agent

Site Location

Proposed Earth Changes

Soil Erosion and Sedimentation Control Plan

Parties Responsible for Earth Change

SESC Installation and Construction Schedule

Additional Documents