Application for Withdrawl of Wetland Credits from the Minnesota Wetland BankApplication for Withdrawal of Wetland Credits from the
Minnesota Wetland Bank
3. Government Entity Approval/Authorization
By signature below, I authorize this wetland credit withdrawal for the identified project.
WCA LGU: City of Albertville LGU Representative: Adam Nafstad/Todd Javens
Signature: Date: �11G13
By signature below, I auth rize this wetland credit withdrawal for the identified project. ^ _ _ _ _ _ _ _ _ _ _ _
Agency Name:
E-mail address: Signature:
4. Withdrawal Information
To be completed by seller of credits.
Fee Calculation (pick one method):
Account Number: 1411
1) Fee per credit (see Fee Schedule on BWSR website) X total credits = $
2) Total Cost of Credits X .065 = $ 426.26
Attach check payable to Minnesota Board of Water and Sail Resources.
Representative:
Date:
By signature below I (seller) authorize the debiting of this account and attest that the credits have not been sold
nor have I agreed to sell them to another user, and this debit will not result in a negative account balance. I also
attest that the sale price reflected in the credit cost is accurate for fee purposes.
Signature:
When this form is completed and all required signatures are obtained, send to:
Wetland Bank Administration
Minnesota Board of Water and Soil Resources
520 Lafayette Road North
Saint Paul, MN 55155
j' Date:
BWSR form 1/24/13 Page 2 of 2
Replacement Plan Approval Conditions. In addition to any conditions specified by the LGU, the
approval of a Wetland Replacement Plan is conditional upon the following:
❑ Financial Assurance: For project -specific replacement that is not in -advance, a financial assurance
specified by the LGU must be submitted to the LGU in accordance with MN Rule 8420.0522, Subp. 9
(List amount and type in LGU Findings).
❑ Deed Recording: For project -specific replacement, evidence must be provided to the LGU that the
BWSR "Declaration of Restrictions and Covenants" and "Consent to Replacement Wetland" forms
have been filed with the county recorder's office in which the replacement wetland is located.
® Credit Withdrawal: For replacement consisting of wetland bank credits, confirmation that BWSR
has withdrawn the credits from the state wetland bank as specified in the approved replacement plan.
Wetlands may not be impacted until all applicable conditions have been met!
LUU Autorizea Ninature:
Signing and mailing of this completed form to the appropriate recipients in accordance with 8420.0255,
Subp. 5 provides notice that a decision was made by the LGU under the Wetland Conservation Act as
specified above. If additional details on the decision exist, they have been provided to the landowner
and are available from the LGU upon request.
Name Title
Adam Nafstad City Administrator/Engineer/Public Works
Director
Signature Date Phone Number and E-mail
(763)497-3384
%, anafstad@ci.albertville.mn.us
THIS DECISION ONLY APPLIES TO THE MINNESOTA WETLAND CONSERVATION ACT.
Additional approvals or permits from local, state, and federal agencies may be required. Check with all
appropriate authorities before commencing work in or near wetlands.
Applicants proceed at their own risk if work authorized by this decision is started before the time period
for appeal (30 days) has expired. If this decision is reversed or revised under appeal, the applicant may be
responsible for restoring or replacing all wetland impacts.
This decision is valid for three years from the date of decision unless a longer period is advised by the TEP
and specified in this notice of decision.
BWSR Forms 7-1-10 Page 2
.. L' A
18. ADDITIONAL INFORMATION REQUIRED FOR PROJECT -SPECIFIC REPLACEMENT (Required only if you marked Box B or Box C in Section 14):
For projects involving at least some project -specific replacement, include the following additional information:
❑ Two drawings to scale of the replacement wetland. Include both overhead view and profile (side view or cross -sectional view). See What to Include on Plans
(Instructions, Page 3) for a detailed description of what should be included in these drawings. Without drawings, your application will be considered incomplete.
❑ For created replacement wetlands, include additional soils information (if available) that indicates the capability of the site to produce and maintain wetland
characteristics.
Note 1: For replacement wetlands located on pipeline easements, you need to receive endorsement of your project from both the easement holder and the Minnesota
Department of Public Safety's Office of Pipeline Safety. Before start of construction, the owner of any utilities must be notified. The landowner or contractor is
responsible for giving this notice by calling "Gopher State One -Call" at 652--454-0002 (Twin Cities Metro Area) or 1-800-252-1166 (all other locations).
Note 2: For extensive or complex projects supplementary information may be requested at a later dated from one or more of the responding agencies.
Such information may include (but not be limited to) the following: topographic map, water table map, soil borings, depth soundings, aerial photographs,
environmental assessment and/or engineering reports.
19. SIGNED AFFIRMATION:
FOR PROJECTS INVOLVING REPLACEMENT BY WETLAND BANDING ONLY. To the best of my knowledge and belief, all information in Part II is true,
complete and accurate; and I affirm that the wetland losses will be replaced via withdrawal from an account in the State Wetland Bank.
FOR PROJECTS INVOLVING ErrHER PROJECT -SPECIFIC REPLACEMENT ONLY OR A COMBINATION OF WE, BANKING
AND PROJECT -SPECIFIC REPLACEMENT:
Part A. The replacement wetland. I affirm that the replacement wetland was not:
Previously restored or created under a prior approved replacement plan or permit; AND
Drained or filled under an exemption during the previous 10 years; AND
Restored with financial assistance from public conservation programs; AND
Restored using private funds, other than landowner funds, unless the funds are paid back with interest to the individual or organization that funded the restoration; and
the individual or organization notifies the local government unit in writing that the restored wetland may be considered for replacement.
Part B: Additional assurances (check all that apply):
❑ The wetland will be replaced before or concurrent with the actual draining or filling of a wetland.
❑ An irrevocable bank letter of credit, performance bond, or other acceptable security has been provided to guarantee successful completion of the wetland replacement.
® The wetland tosses will be replaced via withdrawal from an account in the State Wetland Bank.
Part C. For projects involving any project -specific replacement: Within 30 days of either receiving approval of this application or beginning work on the project, I
will record the Declaration of Restrictions and Covenants on the deed for the property on which the replacement wedand(s) will be located; and I will at the same time
submit proof of such recording to the LGU.
To the best of my knowledge and belief, all information in Part II is true, complete and accurate; and I affirm all statements in Part A and C, as well as
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FOR LGU ONLY
Replacement plan is (check one): [iApproved ❑Approved w4 conditions (conditions attached) ❑ Denied
ZaZ 9Ial-i3
LGU offf�sigrtanfre Date
LGU has receive evidence of title and proof of recording of Declaration of Restrictions and Covenants for Replacement Wetland:
County where recorded
Date
Document # assigned by recorder
LGU official signature Date
Minnesota Local/State/Federal Application Forms for Water/Wetland Projects
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