Storm Water Application for More Than 2 Acres Disturbed D 3306 Cicacenter Form

STANDARD APPLICATION FORM FOR CONSTRUCTION SITES DISTURBING MORE THAN 2 ACRES SOUTH CAROLINA DEPARTMENT OF HEALTH ENVIRONMENTAL CONTROL STORMWATER MANAGEMENT See Reverse for Instructions Submission of this application constitutes notice that the party identified in Section 2 of this form intends to be authorized by a NPDES permit issued for storm water discharges associated with construction activity in the State of South Carolina* Becoming a permittee obligates such discharger to comply with the terms and conditions of the permit. ALL NECESSARY INFORMATION MUST BE PROVIDED ON THIS FORM. Section 1 DATE FACILITY NAME OR PROJECT NAME COUNTY LOCATION also shown on location map LATITUDE TAX MAP CITY/TOWN LONGITUDE USGS QUAD NAME NEAREST RECEIVING WATER BODY DISTANCE TO NEAREST RECEIVING WATER BODY ULTIMATE RECEIVING WATER BODY PROPERTY OWNER OF RECORD ADDRESS PHONE DAY NIGHT FAX PERSON FINANCIALLY RESPONSIBLE FOR THE LAND DISTURBING ACTIVITY if different than above AGENT OR CONTACT PERSON if applicable MOBILE ENGINEER TECHNICAL REPRESENTATIVE OR FIRM CONTRACTOR OR OPERATOR if known SIZE TOTAL acres SURFACE AREA OF LAND DISTURBANCE acres IS THIS PART OF A LARGER COMMON PLAN FOR DEVELOPMENT OR SALE IF YES WHAT IS THE STATE PERMIT NUMBER FOR THE PREVIOUS APPROVAL WHAT IS THE NPDES PERMIT COVERAGE NUMBER HAS A NOTICE OF TERMINATION NOT BEEN SUBMITTED FOR THE NPDES PERMIT COVERAGE 10. SIC CODE SIC code only required if site disturbs 5 acres or more IS THE SITE LOCATED ON INDIAN LANDS if site disturbs 5 or more acres 11. TYPE OF PROJECT FEES please circle the type of activity a* Federal - State - Local - School Exempt from STATE fees NPDES fee may apply b. Industrial - Commercial - Residential - Part of a Larger Common Plan for Development or Sale 100 per disturbed acre max. 2 000 per project In addition a 125 NPDES administration fee will be required on all Projects disturbing 5 acres or more TOTAL FEE DHEC 3306 08/2002 12. START DATE COMPLETION DATE 13. ARE THERE ANY WETLANDS LOCATED ON THE PROPERTY IF YES HAVE THE WETLANDS BEEN DELINEATED ARE ANY WETLANDS BEING IMPACTED BY THIS PROJECT CERTIFICATION 15. I HEREBY CERTIFY THAT ALL LAND DISTURBING CONSTRUCTION AND ASSOCIATED ACTIVITY PERTAINING TO THIS SITE SHALL BE ACCOMPLISHED PURSUANT TO AND IN KEEPING WITH THE TERMS AND CONDITIONS OF THE APPROVED PLANS* I ALSO CERTIFY THAT A RESPONSIBLE PERSON WILL BE ASSIGNED TO THE PROJECT FOR DAY-TO-DAY CONTROL* I CERTIFY UNDER PENALTY OF LAW THAT THIS DOCUMENT AND ALL ATTACHMENTS WERE PREPARED UNDER MY DIRECTION OR SUPERVISION IN ACCORDANCE WITH A SYSTEM DESIGNED TO ASSURE THAT QUALIFIED PERSONNEL PROPERLY GATHERED AND EVALUATED THE INFORMATION SUBMITTED. BASED ON MY INQUIRY OF THE PERSON OR PERSONS WHO MANAGE THE SYSTEM OR THOSE PERSONS DIRECTLY RESPONSIBLE FOR GATHERING THE INFORMATION THE INFORMATION SUBMITTED IS TO THE BEST OF MY KNOWLEDGE AND BELIEF TRUE ACCURATE AND COMPLETE* I AM AWARE THAT THERE ARE SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION INCLUDING THE POSSIBILITY OF FINE AND IMPRISONMENT FOR KNOWING VIOLATIONS* PRINTED NAME OWNER/PERSON FINANCIALLY RESPONSIBLE Engineer may not sign for the owner SIGNATURE 16. I HEREBY GRANT AUTHORIZATION TO THE DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL AND/OR THE LOCAL IMPLEMENTING AGENCY THE RIGHT OF ACCESS TO THE SITE AT ALL TIMES FOR THE PURPOSE OF ON SITE INSPECTIONS DURING THE COURSE OF CONSTRUCTION AND TO PERFORM MAINTENANCE INSPECTIONS FOLLOWING THE COMPLETION OF THE LAND DISTURBING ACTIVITY. 17. DESIGNER CERTIFICATION - ONE COPY OF THE PLANS ALL SPECIFICATIONS AND SUPPORTING CALCULATIONS FORMS AND REPORTS ARE HEREWITH SUBMITTED AND MADE A PART OF THIS APPLICATION* I HAVE PLACED MY SIGNATURE AND SEAL ON THE DESIGN DOCUMENTS SUBMITTED SIGNIFYING THAT I ACCEPT RESPONSIBILITY FOR THE DESIGN OF THE SYSTEM. FURTHER I CERTIFY TO THE BEST OF MY KNOWLEDGE AND BELIEF THAT THE DESIGN IS CONSISTENT WITH THE REQUIREMENTS OF TITLE 48 CHAPTER 14 OF THE CODE OF LAWS OF SC 1976 AS AMENDED AND PURSUANT REGULATION 72-300. THREE SETS OF PLANS ARE REQUIRED FOR FINAL APPROVAL ENGINEER S*C. REGISTRATION NUMBER TIER B LAND SURVEYOR LANDSCAPE ARCHITECT INSTRUCTIONS Who Must File A Standard Application Form For Construction Sites Disturbing More Than 2 Acres Any public federal state local or school or private industrial commercial and/or residential subdivision project that will be engaging in any land disturbing activity that disturbs an area of greater than two 2 acres. Completing The Application Where To File Horry County SCDHEC Office of Ocean and Coastal Resource Management Myrtle Beach Regional Office 1705 North Oak Street Suite 6 Myrtle Beach SC 29577 843 626-7217 Section 1 Location Information Beaufort Colleton and Jasper Counties Beaufort Regional Office 104 Parker Drive Beaufort SC 29906 843 846-9400 Berkeley Charleston Dorchester and Georgetown Counties Charleston Main Office 1362 McMillan Avenue Suite 400 Charleston SC 29405 843 744-5838 Clarendon County Clarendon Soil and Water Conservation District 9B West Rigby Street Manning SC 29102 803 435-2612 Greenville County 301 University Ridge Suite 4500 Greenville SC 29601 864 467-2756 City of Greenville P. O. Box 2207 Greenville SC 29602 864 467-4400 Lexington County County Administration Building 212 South Lake Drive Lexington SC 29072 803 359-8121 You must type or print in the appropriate areas only. Direct any questions you may have to 803 898-4300 or the appropriate implementing agency. Enter the name of the project or facility where the land disturbing activity will be taking place. Enter the location of the activity. If the nearest receiving waterbody is un-named describe the waterbody Eg. Tributary to Black Creek. Section 2 Personal Information questions 3 through 7 Section 3 General Information Enter the total area of the project area in acres. Enter the total sur face area in acres of the land that will be disturbed* If two 2 acres or less please refer to Standard Reporting Form For Phased projects would normally be part of a larger common plan for development or sale 10. List the Standard Industrial Classification SIC code as needed* Enter yes or no as appropriate if the site is located on Indian lands. Only needed if site is 5 acres or greater NOTE SIC CODES ONLY REQUIRED IF SITE DISTURBS 5 OR MORE ACRES SIC CODES GENERAL BUILDING CONTRACTORS Single-family housing construction Residential construction nec* Operative builders Industrial buildings and warehouses Nonresidential construction nec* HEAVY CONSTRUCTION Highway and street construction Bridge tunnel elevated highway Water sewer and utility lines Heavy construction nec* SPECIAL TRADE CONTRACTORS Excavation work Wrecking and demolition work Town of Chapin PO Box 183 Chapin SC 29036 803 345-2444 Richland County of Public Works Administration Engineering 400 Powell Road Columbia SC 29203 803 735-7305 Spartanburg County P. O. Box 1633 Spartanburg SC 29304 864 596-3584 City of Spartanburg P. O. Drawer 1749 Spartanburg SC 29304-1749 864 596-2107 11. Circle the appropriate type of project. If your project is listed in the a category and disturbs less than 5 acres enter EXEMPT for the total fee. If your project is listed in the b category then enter the total fee. 100 per disturbed acre Maximum 2 000 per project plus 125 if 5 acres or greater disturbance. 12. Enter the actual start and completion dates or a best estimate. Sumter County and the cities of Sumter and Mayesville Sumter Soil and Water Conservation District 101 South Main Street Federal Building Room 101 Sumter SC 29150 803 775-8732 York County York County Planning and Development Services 1070 Heckle Blvd. Box A-5 Rock Hill SC 29732 803 909-7214 13. Enter yes or no as appropriate. Enter yes if there are wetlands of any type jurisdictional or non-jurisdictional. If yes delineation must be included on the plan* significantly affected by higher rates of stormwater flow from the site. Section 4 Certification ALL OTHER COUNTIES Department of Health Environmental Control Stormwater Permitting Section 2600 Bull Street Columbia SC 29201-1708 803 898-4234 For questions 15 through 17 please read the certification* Have appropriate person s sign and date the certification*.