Stormwater Management Permit – Major Land Disturbance All fields marked * are required. Property Owner's Information Name*: Email*: Address*: Telephone*: Project Information Project location*: Type of Earth Disturbance Activity (complete all that apply)*: New impervious or semi-impervious surface: (sq. ft/ac.) Diversion or piping of natural or man-made watercourse: (linear feet) Installation of the following: CulvertDetention BasinRetention BasinSediment Basin Removal of ground cover, grading, filling or excavation: (sq. ft/ac.) Storm Water Management Plan Prepared By*: Address*: Telephone*: Please complete the following if different than the owner) Name of Applicant: Address: Telephone: I agree that the information in this form is true and correct to the best of my knowledge.