Fillable Land Disturbance Permit Application SECTION 1 Project Information (City of Salina)

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Land Disturbance Permit Application SECTION 1 Project Information (City of Salina)

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The Land Disturbance Permit Application SECTION 1 Project Information (City of Salina) form is 6 pages long and contains:

  • 3 signatures
  • 13 check-boxes
  • 65 other fields

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File type: PDF

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Land Disturbance
Permit Application
Public Works Department / Engineering Division 785-309-5725
SECTION 1
For Office Use Only
Development No.:
Method of Payment: Cash Check
Credit Card (MC, V)
Fee:
Reviewed by: _______________Date _____
Project Information
Date:
Name of Project:
Address of Work:
Legal Description:
SECTION 2
Project Type
Work Type: Indicate type of work requested under this permit (Note: only check items for work shown on the
plans – other work can be added by amending the plans/permit)
Single Family Subdivision Commercial Development Utility Extension
City Project Other (specify)
Is the proposed utility work within the public street right-of-way?
Yes No
If yes, utility work within the public street right-of-way also requires a separate right-of-way excavation permit.
This permit can be obtained from the Public Works Department, 300 West Ash Street, 785-309-5725.
Does work include construction of any sitework, filling or construction/remodeling of any building area in the
FEMA regulated floodplain?
No Yes If yes, a floodplain development permit is required.
Land Area Disturbed
Acres
SECTION 3
Contact Information
Applicant Information: Applicant must be the developer/owner for work related to development projects, or
the utility company for nondevelopment related utility work.
Applicant: Contact Name:
Address:
Telephone:
Fax:
Cell: E-Mail:
Land Disturbance App Page 1 of 2 09/13
Land Disturbance
Permit Application
785-309-5725 Public Works Department / Engineering Division
SECTION 3 (Cont’d)
Responsible Contractor(s): Include all contractors responsible for land disturbance activities – example,
sanitary sewer, paving, storm sewer, grading, street lighting. Attach additional sheets if necessary.
Contractor 1: Type of Work:
Contact Name: Address:
Telephone: Fax:
Cell: E-Mail:
Contractor 2: Type of Work:
Contact Name: Address:
Telephone: Fax:
Cell: E-Mail:
Contractor 3: Type of Work:
Contact Name: Address:
Telephone: Fax:
Cell: E-Mail:
Project Designer:
Designer: Contact Name:
Address: Telephone:
Fax: Cell: E-Mail:
SECTION 4
Plans
Attach drawings showing all proposed work, limits of construction and proposed erosion and sediment control
plan. This application must be accompanied by a completed Land Disturbance Plan Checklist.
Applicant Name: (Please Print)
__________________________________________________________
Applicant Signature Date
Land Disturbance App Page 2 of 2 09/13
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2
STORM WATER POLLUTION PREVENTION PLAN
Typical Residential Lot
Project Owner_____________________________
Site Address_______________________________
Salina, Kansas 67401
CONTRACTOR’S CERTIFICATION and DELEGATION
I certify under penalty of law, that I understand the terms and conditions of the National
Pollutant Discharge Elimination System (NPDES) Construction General Permit (CGP) that
authorizes the storm water discharges associated with industrial activity from the construction
site identified as part of this Certification. I understand that I am legally required under the Clean
Water Act, to ensure compliance with the terms and conditions of NPDES storm water CGP and
this Storm Water Pollution Prevention Plan (SWPPP).
I understand that I am fully responsible for all subcontractors who perform work activities
on the construction site, to comply with all provisions and requirements of the NPDES storm
water CGP and this SWPPP.
Contractor :
Authorized Representative:
Title:
Address:
Signature, Date:
As Contractor, I have delegated SWPPP compliance and inspection responsibilities to the
following individual for the duration of construction activities for which this company is under
contract with this project.
Contractor SWPPP Representative:
Title:
Signature, Date:
Phone:
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Land Disturbance Permit Application SECTION 1 Project Information (City of Salina)

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Completed 16 July 2020

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