Date _____________
ALLEGAN COUNTY HEALTH DEPARTMENT
3255 – 122nd Avenue, Suite 200, Allegan, MI 49010
Environmental Health
Receipt ___________
269-673-5415 FAX 269-673-4172
APPLICATION FOR SOIL EROSION AND SEDIMENTATION CONTROL PERMIT
Amount __________
It is our goal to process all applications within 21 business days
The fees for SESC are a combination of the following: (1) Plan Review (2) Monthly Inspections (3) Permit
(1) Plan Review: TWO complete sets of plans must be attached Plan Preparer’s Name ______________________ Phone ______________
Less than 1 acre of soil disturbed
Lot Size W ____ X L___ = Sq. Ft. ______
$ 25.00
________
1 - 5 acres disturbed
Number of acres _____
$ 50.00
________
6 acres or more disturbed
Number of acres _____
$ 75.00
________
(2) Inspection Fees: Inspection fees based upon time line presented. Monthly inspections may vary based on scope of project but ar e r equired until per manent
vegetative cover is established. Additional inspections may be required due to non-compliance on the part of the permit holder and will be billed separately.
Fee per each monthly inspection - residential sites
# of months ______ @ $ 25.00
________
Fee per each monthly inspection - commercial sites
# of months ______ @ $ 50.00
________
(3) Permit Fee:
(Based on the type and size of project: residential, commercial, utilities, mining)
Residential - Single family or Duplex
New Construction
$80.00
_______
Existing with addition, improvements, garage, etc.
$40.00
_______
Commercial - Plat developments, mobile home parks, multiple units or multi-family units, commercial/industrial projects, cut & fill operations, etc.
Up to 1 Acre
$100.00
_______
Each additional acre or fraction thereof
# of acres/fractions _____
@ $ 25.00
_______
Utilities - including but not limited to underground cables, conduit or pipelines)
Up to 1 mile
$100.00
_______
Each additional mile or fraction thereof
# of add. miles/fractions ____ @ $ 35.00
_______
Mining - Sand/Gravel - one annual fee, NO plan review or per inspection fee.
$200.00
_______
TOTAL
Fee Schedule Revised Effective: February 2, 2014
________
OWNER INFORMATION (Par ty Responsible for Ear th Change)
NAME ________________________________________________________________
ADDRESS _______________________________________________CITY ________________________ ZIP________________
HOME or CELL __________________________WORK PHONE_____________________ EMAIL ________________________
APPLICANT INFORMATION (IF DIFFERENT FROM OWNER - COMPLETE DESIGNATED AGENT FORM)
NAME ______________________________________________________COMPANY ___________________________________
ADDRESS ___________________________________________CITY __________________________ ZIP _________________
HOME or CELL _________________________WORK PHONE_______________________ EMAIL _______________________
PROPERTY LOCATION INFORMATION
TAX ID 03-_______-________-________-________
ADDRESS ___________________________________ (if assigned)
CITY ___________________________ ZIP______________
TOWNSHIP _____________________ SUBDIVISION _________________ LOT # _____ SECTION # _____ TOWN ____ RANGE____
PROPOSED EARTH CHANGE
Describe Project ____________________________________________________________________________________________
__________________________________________________________________________________________________________
Total Size of earth change (sq. ft.) ___________
Project Start Date ___/____/____Proposed Completion Date ____/____/____
Name of Nearest Body of Water ____________________________________ Distance to Nearest Body of Water _____________
STORM WATER OPERATER - For projects over 1 acres of disturbance.
NAME ______________________________________________________
PHONE _____________________________________________________
COMPANY ___________________________________
LICENSE NUMBER ____________________________
I (we) affirm that the above information is accurate and that I (we) will conduct the above described earth change in accordance with Part 91, Soil Erosion and Sedimentation
Landowners Signature
__________________________________________________________________
Print Name
_____________________________________________
Date
__________________________
Designated Agent Signature
Print Name
Date
690.1.2b
Rev. 2/8/17
THIS PAGE MUST BE INCLUDED WITH APPLICATION AND PLANS
H
a
V
e
N
e
e
d
SITE PLAN REQUIRMENTS FOR SOIL EROSION PERMITS
R. 323.1703 Administrative Rules for Part 91
All of the following must be included on the plans.
Drawing must be to scale (map scale: 1”= 200’ or less)
Site location map showing nearest road intersection
Legal description of property (i.e. T35N, R25W, Section 17, NW1/4, NE1/4)
Location and size of each proposed earth change (clearly defined ON DRAWING)
Soils information (on drawing or in written form)
Distance to nearest water body (lake, stream, river, county drain, wetland, etc.) for each proposed earth change
Location of all existing and proposed drainage and dewatering facilities
Slope information or topography
Location and detailed description of all temporary erosion and sedimentation control measures (shown on drawing)
Location and detailed description of all permanent erosion and sedimentation control measures (shown on drawing)
Timing and sequence of construction (construction schedule)
Location and size of all temporary soil stockpiles
Major geographic and vegetative features
Location and size of all existing buildings and structures
Location of all tree lines and forested areas
Types of Earth Changes Check All That Apply
Single family residence (new)
Commercial/industrial (new)
Road
Single family residence (additions)
Commercial/industrial (additions)
Pipeline
Garage (addition or detached)
Residential (subdivision, multi -family)
School/church
Pole barn
Recreation development
Utility
Pool (in ground)
Golf course
Hospital
Pond
Wetland mitigation
Other
Approximate Project Timing (Month/Year)
MINOR PROJECTS
MAJOR PROJECTS
____/____ Temporary SESC Measures Installed
____/____ Gravel Drive/Entrance Installed
____/____ Land Cleared or Excavation Started
____/____ Final Grading/Seeding
____/____ Permanent Erosion Control Measures in Place
____/____ Temporary SESC Measures Removed
____/____ Temporary SESC Measures Installed
____/____ Gravel Drive/Entrance Installed
____/____ Land Cleared or Excavation Started
____/____ Detention/Retention/Sediment Ponds Installed
____/____ Road Constructed
____/____ Utilities Installed
____/____ Final Grading/Seeding
____/____ Catch Basins/Ponds Cleaned
____/____ Permanent SESC Measures in Place
Additional Earth Change Information
Has earth -moving activity started?
Y
N
Is the earth -moving activity over 1 acre?
Y
N
Will work be occurring in a wetland?
Y
N
If yes, contact MDEQ
Will de-watering occur?
Y
N
If yes, special requirements may apply
Will work be occurring in a waterway/floodplain?
Y
N
If yes, contact MDEQ
Will a designated county drain be affected?
Y
N
If yes, contact the Allegan County Drain Office
Will fill be brought on-site?
Y
N
Amount in cubic yards:
Will material be removed from the site?
Y
N
Amount in cubic yards:
690.1.2b
Rev. 2/8/17
ALLEGAN COUNTY HEALTH DEPARTMENT
3255 – 122nd Avenue, Suite 200, Allegan, MI 49010
Environmental Health 269-673-5415
DESIGNATED AGENT ASSIGNMENT FORM
Date _______________________
I authorize ___________________________________________________________
to act as my
representative in regard to Soil Erosion and Sedimentation Controls at my property located at
____________________________________________________________________________.
In doing so, I agree to the specified requirements on the Soil Erosion and Sedimentation Control permit.
_________________________________________________
Landowners Signature
_________________________________________________
Phone Number
I (we) affirm that the above information 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 Resources and Environmental Protection Act, 1994 PA 451,a s amended, applicable
local ordinances and the documents accompanying this application.
690.1.2b
Rev. 2/8/17