Application For Stormwater Permit

Download Word Document Version

La Porte County Application for an Erosion and Sediment Control Permit

"*" indicates required fields

Project Name*

Project Location Description*

Hydrologic Unit Code*

Receiving Water/Point of Discharge*

Plan Submittal Date*

Civil Township

Quarter

Section

Township

Range

Latitude and Longitude*

Total Project Acreage*

Area of Disturbance >10,000 sq. ft. AND Within 50ft of a Waterway*

Yes

Acreage to be Disturbed*

Number of Lots*

Parcel Number

Project Site Owner

Project Site Owner*

Contact Name*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

FAX

Email*

Plan Preparer

Plan Preparer Name*

Company Name*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

FAX

Email*

Contractor/Builder Contact*

Phone*

Site Erosion Control Supervisor*

Phone*

Cell Phone

FAX

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Submit Files of the Following or Provide Physical Copies to Our Office:

- Construction Plans including Plat and Legal Description
- Copy of Stormwater Pollution Prevention Plan for Construction Sites
- Copy of Post-Construction Stormwater Pollution Prevention Plan, with calculations if applicable
- Copy of LaPorte County Application for Erosion and Sediment Control Permit (this form)
- Copy of Post Construction Operations and Maintenance Manual
- Copy of Proof of Publication of Notice of Intent in Local Newspaper

Drop files here or

Max. file size: 48 MB.

Hidden

Tier 1 Base Fee

<=1 Acre

Hidden

Tier 2 Base Fee

1-20 Acres

Hidden

Tier 3 Base Fee

20-40 Acres

Hidden

Tier 4 Base Fee

40-80 Acres

Hidden

Tier 5 Base Fee

Greater than 80 Acres

Hidden

Waterway Fee

Site Development Fee

Please remit check payable to La Porte County MS4.

Signature

Your Name*

First Last

Entity*

Title*

Date*

Signature*