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Butte Silver Bow Storm Water Management Permit Application Permit Number Date Submitted Final Stabilization Date Project Owner Fax: Mobile: Other: Phone: Email: Zip: State: Butte-Silver Bow Public Works Department NOTE: In addition to this application, applicant must submit all required information in the attached checklist. Mailing Address: Company: Contact Information 125 West Granite St. Butte, MT 59701 (406) 497 - 6515 NOTE: This permit is separate from any permits required by the Montana Department of Environmental Quality. A State Storm Water Construction Permit is required for all disturbance activities equal to or greater than one acre or for land disturbance activities less than one acre that are part of a larger common plan of development or sale that would disturb one acre or more. **No land disturbance is permitted on any project site without an approved Butte Silver Bow Storm Water Management Permit** Contact Person: Contractor Contact Person: Company: Mailing Address: State: Zip: Lot Number: Subdivision (if applicable): Project Information Phone: Email: Fax: Mobile: Other: Engineer Fax: Contact Person: Company: Mailing Address: State: Zip: Phone: Email: Utility □ Project Size: (Land Disturbance) Mobile: Other: Project Address: □ □ □ Highway / Road □ □ Commercial / Industrial Other (describe): □ □ Nature of Construction Check the appropriate box(es) or provide a brief description that indicates the general nature of the construction activities. Single Family Residential Multi-Family Residential LESS than one acre GREATER or equal to one acre Description of proposed work: SWM Permit Application 1 of 2 ---PAGE BREAK--- Butte Silver Bow Storm Water Management Permit Application Permit Number Date Submitted Final Stabilization Date GREATER or equal to one acre Received By Date MT Stormwater Discharge Permit (NOI) Yes No Yes No Site Map Showing BMPs Yes No Yes No Yes No Yes No Yes No Waterbodies and Storm Conveyance Systems Other: Rivers: Lakes: Sloughs: Wetlands: Streams: Start Date: Completion Date: Final Stabilization Date: Project Schedule List Waterbodies within 200' of project I certify that I am the Owner or Owner's authorized agent. If acting as an authorized agent, I further certify that I am authorized to act as the Owners agent regarding the property at the above-referenced address for the purpose of filing applications for decistions, permits, or review under the Butte Silver Bow Storm Water Ordinance and have full power and authority to perform on behalf of the Owner all acts required to enable the City to process and review such applications. Acknowledgement Certificate Pipe Inlets / Outlets: Detention Ponds: Ditches: Gutter: Storm Drain Inlets: Swales: Approval City Comments: List Storm Conveyance Systems within 100' of project I certify that the information on this application is true and correct and understand that I shall not start this project until this application is approved. I shall comply with the laws of the State of Montana and the ordinances of Butte Silver Bow. Date Signed Signature of Legally Responsible Person (Submission must include original signature) Name (printed) Title ***For Official Use Only*** SMP Plan SMP Checklist MT Stormwater Discharge Permit (NOT) SMP Map Field Visit SWM Permit Application 2 of 2