HomeMy WebLinkAboutExcavating & Filling Permit
CITY OF PRIOR LAKE
APPLICATION FOR
EXCA V ATING/FILLING PERMIT
Permit No. Ol)j- IS-
Date I'd- ,-.llJ 0 I
447-4230
Applicant Ill.; t~ /\~ I () ~ n -,S: I
Address: \)foO (. J Lt s- T~ ~ (~.1 <~) Aft-;J I.. tz, I/;
Property Owner: jl7 {Jib y'"11...lt/ e r.,-;v,S -r-~
Address:
Contractor: /~(' ;In ...,.'" (,/ C lfi.. i> ) ,
Address:
Phone# ~J,t/3:J,7(dlJ1
/J7A '
Phone #
Phone #
Consultant Engineer/Surveyor
Address:
Location of Property: Sv no wv / + C / fl e..,J 'f ~
Legal Description: L -r () . (" - l) (]. r; &
Will the excavation or filling be in a: Walen:OUlSe tin Wetland t1 () Up~ ---It ~ < S;
I'Iupose for the proposed excavaling or filling: M b; ~ (5,~ <('1 ,0 t: L, ::.
So P61fltla f)/;Ju.-:)...,~...,_ u.Jill (1/0/2 ( ~{.~/)L)>}
...,. ~ R, 1 f J (1) 'J-L.L L(?J s j?.LA ~ ;2J'?- PI ~
Estimated start date: 1;)..- ~ (,").... (.J I Completion date: ,.- (c)., (/2.-
What is the type of material to be removed or deposited: C I u....-J-
Phone
#
AI~
In what manner will the material be removed and/or deposited? J j)., ~ ,J!
~ p ,) c:.>.sS $"'7 .0 ~ J-::r-
What highway, street, or other public way will material for removal or depositation be hauled or carried?.5 ,'" i-I '':/ f; 12 ~ I.c
What, if any, street, avenue, lane, alley, highway, right of way, thoroughfare or public ground will be obstructed? () cO~ ~
IT SHALL BE THE RESPONSffiIUTY AND THE BURDEN OF THE APPLICANT TO DEMONSTRATE TO THE SATISFAcnON OF mE CITY
ENGINEER FOR THE CITY OF PRIOR LAKE THAT THE PROPOSED EXCA V AnON AND/OR FILLING COMPLIES WITH mE OVERAU.. CITY
OF PRIOR LAKE STORM WATER MANAGEMENT PLAN. SAID BURDEN SHALL INCLUDE THE FURNISHING OF A REPORT WITH SUPPORT.
ING CALCULA nONS OF A REGISTERED PROFESSIONAL ENGINEER.
Will proposed excavation or depositon affect the City of Prior Lake overall storm water management plan? Yes - No 4 If
yes, show proposed effect.
SUBMISSION REQUIREMENTS:
(A) Completed application fonn (11) Completed legal description (C) Map or plat of the proposed filling Or excavating showing location and amount of material
proposed to be removed of deposited. with a description of the area (D) The depth or heights to which such removal or deposition is proposed throughout the
area and the proposed angle of all slopes to be shown on a 2' contour map at a scale of I" =50' or larger: The proposed and origirial contours shall be shown in-
cluding all property within ISO' of proposed excavation or deposition and shall be signed by an engineer or surveyor registered in the State of M;BDeIOCa .(E)
Erosion control plan (F) Affect on existing utilities (G) Protection of site by erection of suitable fence. guard or barricade (H) Application fee (I) Bond, letter of
credit. or deposit of monies in a sum sufficient to pay the cost of restoring a site. The extra ordinary costs of repairing, highways, streets or other public ways
along designated routes of travel and to pay such expenses as the City may incur by reason of doing anything required to be done (J) Public liability insurance.
Letter of credit, ~. or de. posit of mnney liability insurance provided
SignaOlre ofapplicant ----;- ~ Dale I [)" ~ tJ .f) I
City Engmeer I_~ __ Date~
Permit is valid if signed by City Engineer.
CD tv\ Q'~",-~\ f\ S'l l +-- ~ c...t
(Vili\\ ~O-*-e G? Lf41-963Ll
Amount of bond
$50 QE-
Permit fee
Permit deposit
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