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.