State of West Virginia

Construction Sediment Control Plan

1. Developer/Company Name

Address

Telephone

2. Project Name/Description

3. Preparer’s Name

Address

Telephone

4. Landowner’s Name

Address

5. Type of Construction: Single Family Residence ____ Multi-Family Residence ___ Utility Transmission ____ Commercial Development ____

Industrial Development

Other (Specify)

6.  Location

County Nearest Town/City

Conservation District

7. Project Duration Begin: / / End: / /

Month day year Month day year

8. Attach section of involved USGS 7.5 Minute Topographic Map on separate sheet.

Quadrangle(s) Legend: Construction Site Access Road

9. On separate sheet provide a map of the construction site (may be free hand). Indicate slopes (by arrows), natural drainage, existing vegetated areas and areas to be cleared and proposed roads. (See Item 10) (*Note: Scale on map preferred but not necessary)

SUGGESTED LEGEND

Construction Site Boundary

Existing Road

Sediment Basin Pond

Silt Fence

Open Ditch

Drain Pipe

Access Road Rip Rap Waterway

Stream Dam or Dike Wet Spot

10.  Provide a narrative describing the sequence of operations, how sediment will be controlled and ground cover established, i.e. describe the BMPs to be used, time of installation and BMP maintenance schedule (attach a separate sheet if needed).

______

*Note: 1/ West Virginia Erosion and Sediment Best Management Practice Manual 2006 (http://www.dep.wv.gov/WWE/Programs/stormwater/csw/Pages/ESC_BMP.aspx) as a reference (other BMP Manuals may be acceptable).

2/ All structures should be inspected regularly during the project and repaired if necessary. All sediment shall be disposed of in an approved manner.

11.  Approximate size of the construction site, this should include all land disturbed (access roads, borrow and waste/spoil areas, etc.).

12.  I certify that the above information is correct to the best of my knowledge.

Preparer’s Signature Date

13.  I do hereby certify that all necessary measures will be taken to protect water quality in and adjacent to this project site.

Responsible Party (Please Print) Signature / Date

BELOW THIS LINE TO BE COMPLETED BY THE CONSERVATION DISTRICT

Conservation District

Reviewer’s Name

Date Received Date Reviewed

Field Reviewed Yes No Accepted Yes No

Comments:

______

Reviewer’s Signature ______Date______