Geauga Soil and Water Conservation District

Geauga Soil and Water Conservation District

Application for Review and Approval of Water Management and Sediment Control (WMSC) Plan

All information,as applicable, must be provided on this form. The review and inspection fee shall be submitted with this application, plans and calculations (if applicable). Plans will not be reviewed until the fee has been paid.

1. Owner Information

Name: Phone:

Contact Person: Phone:

Address: Fax:

City: State: Zip: Other Phone/email:

2. Contractor/Homebuilder Information

Name: Phone:

Contact Person: Phone:

Address: Fax:

City: State: Zip: Other Phone/email:

3. Professional Engineer certifying plans/calculations information

Name: Phone:

Contact Person: Phone:

Address: Fax:

City: State: Zip: Other Phone/email:

4. Site Information

Site/Project Name: Township/City/Village:

Address: Project Type:

(subdivision, commercial, government, residential lot,

Condominium, institutional, mobile home park, manufactured

home park or apartment)

City: State: Zip: Parcel #:

Watershed: Total Site (parcel) Acreage: Total Disturbed Acreage:

(Chagrin, Cuyahoga, Grand, Mahoning)

% of disturbed area to entire lot: Total Sublots (if applicable):

Acreage of imperviousness created: % of imperviousness created on parcel:

Description of prior land use:

Proposed Start Date:Estimated Completion Date:

Site Coordinates (in decimal degrees): Latitude N 41. Longitude W -81.

7. Other Natural Resource Permits (if applicable)

Ohio EPA NPDES Construction General Permit #: or date NOI sent:

Are there jurisdictional streams or wetlands on the property that will be disturbed or impacted?:

If so, please provide below permits or proof that no permit is needed.

US Army Corps of Engineers 404 Permit or Nationwide Permit #: or date applied for:

Ohio EPA 401 Water Quality Permit #: or date applied for:

Submit copies of all above permits/correspondence/applications with plan submittal

8. Easements or other Restrictions

Are there any conservation easements on the property?

If so, please explain/describe:

Are there any other restrictions on the property?

If so, please explain/describe:

9. Storm Water Management Information

Storm Water Facility #1 type:

Facility #1 Coordinates (in decimal degrees): Latitude N 41. Longitude W -81.

Storm Water Facility #2 type:

Facility #2 Coordinates (in decimal degrees): Latitude N 41. Longitude W -81.

Storm Water Facility #3 type:

Facility #3 Coordinates (in decimal degrees): Latitude N 41. Longitude W -81.

Storm Water Facility #4 type:

Facility #4 Coordinates (in decimal degrees): Latitude N 41. Longitude W -81.

Storm Water Facility #5 type:

Facility #5 Coordinates (in decimal degrees): Latitude N 41. Longitude W -81.

10. Certification

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision and are to the best of my knowledge and belief, true, accurate and complete. I authorize the Geauga Soil and Water Conservation District (SWCD) agents to enter this property for the purposes of plan review, site inspection or compliance with the Water Management and Sediment Control Regulations for the duration of the project until the Geauga SWCD can close the project and all bare soil is stabilized with vegetation.

Printed Name: Affiliation:

Signature: Date:

Geauga Soil and Water Conservation District

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