Haviland Fields Environmental Assessment Worksheet

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Lower Rum River WMO START OF PROJECT: EST. COMPLETION DATE: APPROVAL DATE: By signing this Permit Application, the undersigned consents and agrees on behalf of the Applicant that: 1. The permit application fee is non-refundable. Escrow deposits will be held by the LRRWMO until the project has been completed and all conditions of issuance of the permit are satisfied. The Applicant is responsible for all expenses incurred by the LRRWMO in the processing, administration and enforcement of the permit application and permit. The escrow deposit will be used to reimburse the LRRWMO for all expenses incurred by the LRRWMO in processing, administering and enforcing the permit application and permit, including engineering, legal and other consultant costs. If such expenses exceed the escrow deposit, the LRRWMO will bill the Applicant or Permittee for such excess amount and payment will be due within twenty (20) days of mailing the invoice. Timely payment of such invoices is a condition of all permits and work may be stopped on the project for failure to make payments when due. 2. The undersigned, its agents, principal, assigns and/or representatives (hereinafter "Permittee") shall abide by all the standard conditions and special terms and conditions of the LRRWMO. 3. Any work that violates the terms of the permit may result in the LRRWMO or the City in which the work is being done immediately causing the work on the project relating to the permit to cease and desist. All work on the project shall cease until the permit conditions are met and approved by the LRRWMO and/or the City in which the work is being done. 4. The Permittee agrees to be bound by the terms of the LRRWMO permit requirements, final permit, standard conditions, and special conditions required by the LRRWMO for approval of the permit. The undersigned has the authority to bind the permit holder, the owner of the property and/or any entity performing work on the property pursuant to the terms of LRRWMO permit, and shall be responsible for complying with terms of the LRRWMO permit. "I certify that I have thoroughly read and understand the above information." Signature of property owner or designated Date Signature of applicant if different from Date Agent (no agent without a letter of authority) property owner Print Signer's name Print Signer's name Application Acknowledged by City: Name of City Official City Date SIGNATURE OF LRRWMO CHAIRMAN: ** **NOTE: Subject to conditions as designated in the WCA Notice of Decision as recommended by the Technical Evaluation Panel and Barr Engineering (see attached) PERMIT IS NOT VALID IF PROJECT HAS NOT STARTED WITHIN ONE YEAR FROM DATE OF APPROVAL Andover - Anoka - Ramsey • 2015 First Avenue • Anoka, MN 55303 • www.Irrwmo.org/ C-2