OFFICE USE ONLY
Barry County Planning Office Permit Fee $______
220 W State St
Hastings MI 49058 Receipt Number ______
(269) 945-1290 (269) 948-4820 Fax
Date Issued ______
Soil Erosion & Sedimentation Control
Permit Application for Part 91, of Act 451 Expiration Date ______
of 1994, as amended
Mail Back ______and FAX to ______

A SITE PLAN IS REQUIRED WITH THE APPLICATION

I) Applicant (Please check if applicant is landowner or designated agent)

Name Landowner Designated Agent
Address
City / State / Zip Code / (Area Code) Telephone Number

II) Location

Section / Town North / Range West / Township / City/Village
Subdivision/Site Condominium / Lot Number(s) or Unit Number(s)
Street Address / Property Tax ID Number
Project Type: Residential Multi-family Commercial Accessory Building Industrial □ Seawall
□ Landscaping Plats or Subdivisions Grading or Mining) □ County Drain Maintenance Other ______

III) Proposed Earth Change

Described Project / Soil Type / Size of Earth Change
(acres or square feet)
Name of Water Course: Lake, River, Stream, Wetlands, or CountyDrain(s)
Distance to Water Course / Project Start Date/Completion Date / Is the parcel hilly or flat

IV) Soil Erosion & Sedimentation Control Plan (Refer to Rule 323.1703)

Note: ______complete sets of plans must be attached / Estimated Cost of Erosion and Sediment Control
Plan Preparer’s Name and Area Code/Telephone Number

V) Parties Responsible for Earth Change

Name of Landowner (if not provided in Box Number 1 above) / Address
City / State / Zip Code / (Area Code) Telephone Number
Name of Individual “On Site” Responsible for Earth Change / Company Name
Address / City / State / Zip Code / (Area Code) Telephone Number

VI) Performance Deposit (If required by the permitting agency)

Amount Required $ ______Cash Certified Check Irrevocable Letter of Credit Surety Bond
Name of Surety Company
Address / City / State / Zip Code / (Area Code) Telephone Number

I (we) affirm that the above information is accurate and that I (we) will conduce the above described earth change in accordance with Part 91, Soil Erosion & Sedimentation Control, of the Natural Resource & Environmental Protection Act, 1994 PA 451, as amended, applicable local ordinance, and the documents accompanying this application.

DESIGNATED AGENT MUST HAVE A written statement FROM THE LANDOWNER giving AUTHORIZation tO SECURE A PERMIT IN THE LANDOWNER’S NAME,

or the landowner must sign the application

______

Landowners SignatureDate

______

Applicant/Designated Agent SignatureDate

OFFICE USE ONLY
Permitted Activity: ______
______
Specific Conditions:______
______
______
______
Accepted Unaccepted Authorized Signature CEA Date

FORM LETTER OF AUTHORIZATION FROM PROPERTY OWNER

Date ______

Property Owner’s Name: ______

Mailing Address: ______

To the Barry County Planning Office:

I give my permission to have:

______

(Please print name and company)

to obtain the Soil Erosion Permit for my property.

Sincerely,

______

(Signature of Property Owner)

This form can be either faxed to our office at (269) 948-4820 or

emailed to:

Date:______Site Plan Drawing Area

Approved□Not Approved□Must be submitted with Soil Erosion Application

Project Address: / Owner Name: / Site plan must include the following:
Parcel Number: / Owner Mailing Address: / Lot dimensions and area
North Arrow
Roads, ROW & Easements
All buildings with sizes
Building setbacks
Utilities (gas, elect, etc.) / Bodies of water w/setback
Well\Septic\Sewer system
Lot coverage
Driveway & parking areas
Zoning District:
Township: / Owner Phone:
Lot Size: / Project Type:
Scale: / Date Drawn: