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City Engineer Brian DeFrang,P.E. <br /> CITY OF WINONA Phone: (507)457-8269 <br /> STORMWATER/EROSION CONTROL Fax: (507)452-1239 <br /> PERMIT APPLICATION E-mail:BDeFrang@ci.wmona.mn.us <br /> A permit application fee shall accompany this permit. (City and Port Authority Projects are not required to pay a fee.) <br /> Applicant acknowledges familiarity with the Rules and Regulations of the City of Winona Stormwater Management <br /> Ordinance. An electronic fill-in form is on our website: http://www.cityofwinona.com/city-services/public- <br /> works/engineering/stormwater-management/ <br /> Property Owner: Contractor: <br /> Company/Individual Company/Individual <br /> Contact Person Contact Person <br /> Mailing Address Mailing Address <br /> City/State/Zip City/State/Zip <br /> E-Mail E-Mail <br /> Office Phone Office Phone <br /> Mobile Phone Mobile Phone <br /> Permit Applicant: Engineer/Architect: <br /> Company/Individual Company/Individual <br /> Contact Person Contact Person <br /> Mailing Address Mailing Address <br /> City/State/Zip City/State/Zip <br /> E-Mail E-Mail <br /> Office Phone Office Phone <br /> Mobile Phone Mobile Phone <br /> SEND TO: City of Winona, City Engineer Brian DeFrang, 207 Lafayette St., PO Box 378, Winona, MN 55987 <br /> NOTE: The Contractor and Applicant assumes all responsibility for compliance with permit conditions. <br /> Signature of Applicant Date Signature of Contractor Date <br /> Project Name Acreage <br /> Address or Parcel ID <br /> Legal 1/4 Section Township Range <br /> Nearest major street intersection Municipality or Township <br /> Purpose of Project <br /> Attached are plans for supporting documents for: <br /> Land Development Bridge & Culvert Construction <br /> Runoff Water Quality Wetland Alteration <br /> Site Drainage Riparian Improvement-Shoreline Setback <br /> Erosion Control Private Drainage System <br /> Floodplain Development Other: Explain <br /> Use and/or Appropriation of Public Water <br /> Start of Project Estimated Completion Time <br /> Is an environmental assessment or environmental impact statement being prepared for this project? <br /> To be completed by , 20 <br /> ----------------- ------------- --------------------------------------------------- ------- <br /> Received by Date - PERMIT FEES - <br /> ❑ Approved Small Site.......................................................$50.00 <br /> Large Site.....................................................$125.00 <br /> ❑ Denied Reason(s): <br /> ❑ Waived Reason(s): Pymt: Cash Check Credit Card Debit Card <br /> (Master Card or Visa) <br /> Signed: Date <br /> Total Cost$ <br /> Receipt# Permit# <br />