Fond Du Lac Reservation Office of Water Protection

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 Phone: 218-878-8022 Fond du Lac Reservation Fax: 218-879-4854 1720 Big Lake Road Email: [email protected] Cloquet, Minnesota 55720