Download WPMO Exempt Form - Fond du Lac Band of Lake Superior Chippewa

FOND DU LAC RESERVATION – OFFICE OF WATER PROTECTION
WETLANDS PROTECTION & MANAGEMENT ORDINANCE (WPMO)
EXEMPTION CERTIFICATE REQUEST FORM
1) Project Name: _______________________________________________________________
2) Project Location Information (attach map or aerial photo of project site):
Address: _____________________________________________________________________
City: _________________________________ State: ___________________ Zip: __________
3) Legal Description of Property:
¼_________ ¼__________ Township_________ Range_________ Section__________
Other Location Information: ____________________________________________________
_____________________________________________________________________________
4) Property Owner Information:
Name: _______________________________________________________________________
Address: _____________________________________________________________________
City: _________________________________ State: ___________________ Zip: __________
Phone: _____________________
5) Exemption Being Requested (Circle One):
* Road Maintenance/Repair (Sec. 303(b)(1))
* Forestry Practices (Sec. 303(b)(5))
* Utility Maintenance/Repair (Sec. 303(b)(2))
* Wetland/Watercourse Restore (Sec. 303(b)(6))
* Agricultural Drain/Irrig. (Sec. 303(b)(3))
* Oil/HazMat Contain/Clean-up (Sec. 303(b)(7))
* Bridge Maintenance/Repair (Sec. 303(b)(4))
* De minimus (Sec. 303(b)(8))
6) Contractor/Logger Information (if different from Property Owner)
Company Name: _______________________________________________________________
Project Supervisor: _____________________________________________________________
Address: ______________________________________________________________________
City: _________________________________ State: __________________ Zip: _____________
Phone: _________________________ Fax: ______________________ Email: ____________________
7) Anticipated Wetland Impacts: Acres: ___________________ Sq. Ft. ______________________
8) Project Purpose:
9) Project Description (attach plan sheet(s) or other applicable information):
10) Wetland Avoidance/Minimization Efforts:
11) Signature of Property Owner (or Designated Representative):
__________________________________________________________________________ Date:
_________________
FOND DU LAC RESERVATION – OFFICE OF WATER PROTECTION
WETLANDS PROTECTION & MANAGEMENT ORDINANCE (WPMO)
EXEMPTION CERTIFICATE REQUEST FORM
INSTRUCTIONS
1) Project Name – Give the name of the project. If no project name is provided, the project name
will be the Property Owner’s name.
2) Project Location Information – Provide the street address for the project location if such an
address exists. Provide the city and state of the project location. Attach a map or aerial photograph
of the project location, indicating the project limits. Indicate any anticipated wetland impacts if
these impacts will be permanent.
3) Legal Description of Property - Provide the legal description of the property as found on the
property title, deed, or property tax statement. Coordinates such as latitude/longitude or UTM can
be provided in the Other Location Information, if known. If more space is needed, please attach
additional sheet(s).
4) Property Owner Information – Provide the name, address, city, state, zip, and phone number of
the property owner where the project will take place.
5) Exemption Being Requested – Circle the exemption being requested for the project. The
references in the parenthesis refer to the applicable exemption as described in the Fond du Lac
Band of Lake Superior Chippewa Wetlands Protection and Management Ordinance (WPMO).
6) Contractor/Logger Information – If the project is being conducted by someone other than the
property owner, provide the company name, name of the project supervisor, address, city, state,
zip, phone, fax (if applicable), and email (if applicable).
7) Anticipated Wetland Impact Area – Provide an estimate of any permanent wetland impacts
anticipated as a result of the project, given in acres or square feet.
8) Project Purpose – Provide a reason for the project, including an explanation as to why wetlands
need to be impacted both temporarily and/or permanently. If more space is needed, please attach
additional sheet(s).
9) Project Description – Provide a description of how the project will be accomplished. Include the
approximate starting and ending dates. If more space is needed, please attach additional sheet(s).
10) Wetland Avoidance/Minimization Efforts – Provide a description of efforts during project
planning to avoid wetlands or minimize wetland impacts for those areas that are unavoidable.
Describe the Best Management Practices that will be utilized on-site to protect wetland and water
quality. If more space is needed, please attach additional sheet(s).
Questions regarding this form may be directed to:
Richard Gitar, Water Regulatory Specialist
Fond du Lac Reservation
1720 Big Lake Road
Cloquet, Minnesota 55720
Phone: 218-878-8022
Fax: 218-879-4854
Email: [email protected]