PLEASE PRINT OUT AND
RETURN ALL COPIES TO:                                                                             #____________________
Thirty Lakes Watershed District
322 Laurel Street, Suite 13
Brainerd, MN 56401

THIRTY LAKES WATERSHED DISTRICT

Storm Water Application and Storm Water Permit

TO BE COMPLETED BY APPLICANT

Name ______________________________________________________________________________________

Address ____________________________________Zip_____________ Phone __________________________

Nature of Work _______________________________________________________________________________

Project Name: _______________________________________________________________________________

Property Address: ____________________________________________________________________________

Real Estate Code (on tax statement):_____________________________________________________________

Location ___________________________________________________________________________________

Optional: I hereby authorize ___________________________________________________________ to act as my authorized agent for the purpose of obtaining an approved stormwater permit.

Procedure to be used to control erosion and sedimentation:

Site and work plan with all measurements will be drawn to scale and attached.

__________________________________________________

Applicant/Agent

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TO BE COMPLETED BY THE DISTRICT

This permit application is hereby denied ____ approved ____ by the Board of Managers of the Thirty Lakes Watershed District this _______ day of ____________, 20____.

Reason for denial:

Conditions of approval: See attached conditions of approval