TOWN OF RAYMOND, RACINE COUNTY, WISCONSIN
APPLICATIONFORLAND DISTURBING CONSTRUCTION ACTIVITIES PERMIT
OWNER/APPLICANT INFORMATION (APPLICANT MUST BE OWNER OF PROPERTY)
CITY, STATE, ZIP CODETELEPHONE NUMBER
TYPE OF OWNERSHIPINDIVIDUAL(S) PARTNERSHIPCOPORATIONOTHER
PARCEL ID NO.STREET ADDRESS
SIZE IN ACRESCITY, STATE, ZIP CODE
EXISTING ZONINGPROPOSED ZONING
PROPOSED STARTING DATEANTICIPATED COMPLETION DATE
AREA TO BE DISTURBED, ACRESEXISTING LAND USE
VOLUME OF MATERIAL TO BE DISTURBED,
10,000 SQUARE FEET OR GREATER
TYPE OF MATERIAL:
BRIEF DESCRIPTION OF PROJECT:
CITY, STATE, ZIP CODETELEPHONE
PROVIDE NAME, ADDRESS, AND TELEPHONE NUMBER OF ALL UTILITIES WITH FACILITIES ON THE PROPERTY.
PROVIDE THE NAME, ADDRESS, AND TELEPHONE NUMBER OF ALL PARTIES WITH EASEMENTS OR RIGHT-OF-WAY ON THE PROPERTY.
INDICATE ALL REGULATORY AGENCIES THAT HAVE BEEN CONTACTED AND INDICATE IF A PERMIT OR APPROVAL
WAS REQUIRED. ATTACH A COPY OF ALL PERMITS AND APPROVALS.
AGENCY PERMIT/APPROVAL REQUIRED
RACINE COUNTY HIGHWAY DEPARTMENTYESNO
RACINECOUNTY PLANNING & ZONINGYESNO
SOUTHEASTERN WISCONSIN PLANNING COMMISSIONYESNO
WISCONSIN DEPARTMENT OF NATURAL RESOURCES – CHAPTER 30 PERMITYESNO
WISCONSIN DEPARTMENT OF NATURAL RESOURCES – STORM WATER YESNO
WISCONSIN DEPARTMENT OF TRANSPORTATIONYESNO
U.S. ARMY CORPS OF ENGINEERSYESNO
NOTES: A list of contacts is available at the Town Hall from the Clerk. The Racine County Highway
Department shall be contacted if the property abuts a county highway or a county highway is used
for moving material. The Wisconsin Department of Transportation shall be contacted if the property
abuts a state or federal highway or a state or federal highway is used for moving material.
CONDITIONS OF PERMIT APPROVAL
I understand that if a permit is granted, I am obligated to do the following:
(1)Notify the town clerk within 48 hours of commencing any land disturbing construction activity.
(2)Notify the town engineer of completion of any BMPs within 14 days after the installation thereof.
(3)Obtain permission in writing from the town engineer prior to modifying the erosion and sediment control plan.
(4)Install all BMPs as identified in the approved erosion and sediment control plan.
(5)Maintain all road drainage systems, stormwater drainage systems, BMPs and other facilities identified in the erosion and sediment control plan.
(6)Repair any siltation or erosion damage to adjoining surfaces and drainageways resulting from land disturbing construction activities and document repairs in a site erosion control log.
(7)Inspect the BMPs within 24 hours after each rain of five-tenths inch or more and at least once each week make needed repairs and document the findings of the inspections in a site erosion control log, with the date of inspection and the name of the person conducting the inspection.
(8)Allow the town engineer or his designee to enter the site for the purpose of inspecting compliance with the erosion and sediment control plan or performing any work necessary to bring the site into compliance with the erosion and sediment control plan.
(9)Keep a copy of the erosion and sediment control plan at the construction site.
Have you attached an Erosion and Sediment Control Plan that contains the requirements set forth in Section 26-40 of the Town’s Code of Ordinances?
Describe any other attachments:
PERMIT FEES (SEE ATTACHED SCHEDULE)
APPLICATION FEE AMOUNT ENCLOSEDREVIEW AND INSPECTION FEE AMOUNT ENCLOSED
NOTE: PROVIDE SEPARATE CHECKS FOR EACH FEE. THE APPLICATION FEE IS NON-REFUNDABLE. THE UNUSED
PORTION OF THE REVIEW FEE WILL BE REFUNDED AT THE COMPLETION OF THE PROJECT.
The Applicant agrees to maintain a balance in the review/inspection fee account of at least 25 percent of the review/inspection fee until the project is completed. The applicant agrees to pay an additional amount equal to 25 percent of the review/inspection fee within one week of being notified by the Town that the balance in the review/inspection fee account has decreased below 25 percent of the original amount or cease all work on the project until the payment is made.
SIGNATURE OF APPLICANTDATE SIGNED:
LAND DISTURBING CONSTRUCTION ACTIVITIES PERMIT FEE SCHEDULE
Application FeeNon-Refundable* $75.00
Site Inspection Deposit ScheduleDeposit based upon area to be
disturbed. Unused portion will be
refunded at the end of the project.
10,000 square feet to less than one acre$150.00
One acre to less than five acres$500.00
Five acres or greaterEngineers to estimate amount of deposit needed
*Pursuant to §26-39, the applicant is obligated to reimburse the Town for engineering and legal costs related to the application, including costs of inspection not covered by the application fee.
FOR TOWN USE
PERMIT FEES RECEIVED
APPLICATION FEE AMOUNTSITE INSPECTION DEPOSIT AMOUNT
RECEIVED BY:DATE RECEIVEDAPPLICATION NO.
THE FOLLOWING ACTION HAS BEEN TAKEN ON YOUR APPLICATIONF OR A LAND
CONDITIONALLY APPROVED, SEE ATTACHED CORRESPONDENCE
NOTICE BY:TITLE:DATE OF NOTICE:
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