Fillable City of Decatur, Illinois (City of Decatur Illinois)

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City of Decatur, Illinois (City of Decatur Illinois)

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U.S.A. forms for City of Decatur Illinois

BROWSE CITY OF DECATUR ILLINOIS (IL) FORMS

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Page 1 of 2
Land Disturbance Permit
City of Decatur, Illinois
Public Works Department
#1 Gary K. Anderson Plaza
Decatur, Illinois 62523
Phone: (217) 424-2747
Fax : (217) 424-2799
PERMIT – TYPE OR USE INK – MUST BE COMPLETED BY PERMITTEE
Name of development:
Address of property permitted for land disturbance:
Legal tax ID(s):
Property owner name / address:
Contact person phone:
Fax:
Cell:
Land disturbance type: (Check one)
Land disturbing activity that disturbs one (1) or more acres of land. ($250 with an additional $50 for every acre past 5, cap at $5000)
Land disturbing activity of less than one (1) acre of land that is part of a larger planned development that affects more than one (1)
acre of land. ($50)
Land disturbing activity of less than one (1) acre of land that poses a unique threat to water, public health or safety. ($100)
Construction or operation of a borrow pit. ($25)
EXEMPT – No permit required (Check one)
Emergency activity immediately necessary for the protection of life, property or natural resources.
Addition or modification to existing single family structure not subject to Land Disturbance Permit.
Existing agricultural use of land – crop production, implementation of approved conservation measures,
or construction of agricultural structures not subject to a Land Disturbance Permit.
Industrial activity with a separate permit.
Legal description of property to be developed (Attach additional sheet if needed.):
Size of area to be disturbed:
square feet
acres
Description of land disturbance:
Sequence of construction activities:
Receiving waters of storm water runoff. If applicable, include location and size of city storm sewer:
Page 2 of 2
Land Disturbance Permit
City of Decatur, Illinois
Public Works Department
#1 Gary K. Anderson Plaza
Decatur, Illinois 62523
Phone: (217) 424-2747
Fax : (217) 424-2799
Primary contractor information, if known. Attach contact information for all subcontractors performing land disturbing
activities.
Name:
Address:
Phone: Fax:
Required attachments:
Attach copy of Notice of Intent filed with the Illinois Environmental Protection Agency (IEPA) as required by General NPDES Permit
ILR10
Attach copies of other environmental permits for the work obtained from other state or federal agencies.
Attach Storm Water Pollution Prevention Plan (SWPPP)
Attach payment in the amount shown next to the appropriate land disturbance type shown on Page 1.
FOR CITY USE
Permit is approved
Permit is approved with the following conditions: ___________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Permit is denied for the following reasons: ________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Date issued: _______________________________ Construction commencement date: _______________________________
Notes:
1. Operators are authorized to discharge storm water from construction site on the date this permit is issued or when
allowed to by the IEPA Notice of Intent, whichever is later.
2. This permit expires 180 days after issuance if no substantial work has commenced or 18 months from the date of
construction commencement.
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City of Decatur, Illinois (City of Decatur Illinois)

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Completed 15 February 2021

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