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Soil Erosion & Sedimentation
Control Permit Application
City of Midland Building Department: 333 West Ellsworth Street: Midland, Michigan 48640: 989-837-3383: Fax 989-835-2378: www.midland-mi.org
Project Information:
Project Name: _________________________________________________________________________________
Site Address: _______________________________________ Parcel Number: _____________________________
Description of Work: ___________________________________________________________________________
Total Parcel Size: _____________________Acres_ Total Disturbed Area*: _________________________Acres
_
*If earth change area is 5 acres or greater, a NPDES (National Pollution Discharge Elimination System) permit must be obtained from MDEQ.
Applicant Information:
Landowner(s): _________________________________________________________________________________
Company Name: ______________________________________________________________________________
Address: _____________________________________________________________________________________
City: ___________________________________ State: __________________ Zip Code: ____________________
Phone Number: Work: ______________________ Cell: ____________________ Fax: ______________________
E-mail Address: __________________________________________________________________
Designated Agent** Information: (check one) Architect/Engineer______ Contractor______ Other _____
Name: _______________________________________________________________________________________
Company Name: ______________________________________________________________________________
Address: _____________________________________________________________________________________
City: _________________________________________ State: _______________ Zip Code: _________________
Phone Number: Work:______________________ Cell: ____________________ Fax: ______________________
E-mail Address: __________________________________________________________________
**
Designated Agent must have written statement from landowner authorizing him/her to secure a permit in landowner’s name.
On- Site Project Contact: ________________________________________________________________________
Name: _______________________________________________________________________________________
Company Name: ______________________________________________________________________________
Address: _____________________________________________________________________________________
City: __________________________________________ State: _______________ Zip Code: ________________
Phone Number: Work:______________________ Cell: ___________________ Fax: _______________________
E-mail Address: __________________________________________________________________
Certified Storm Water Operator:
Name: ____________________________________ Cert. Number: _______________ Exp. Date _______________
I (We) affirm that the information in this application 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 Resource and Environmental Protection Act, Act 451 of the Public Acts of 1994, as amended, it’s
corresponding rules, applicable local ordinances, and the documents accompanying this application. I acknowledge that I have read and will comply with the
general conditions and responsibilities as outlined in the application. This application serves as written consent for the City of Midland to enter onto this site
for the purpose of inspections. This permit does not exempt permit holder from obtaining other permits issued by State or Local agencies.
_____________________________________ _________________________________ _______________
(Landowners Signature) (Print Name) (Date)
_____________________________________________ ________________________________________ __________________
(Authorized Agent Signature) (Print Name) (Date)
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