Full Text
PART 1 of 2: Project Estimated amount of land to be disturbed: Property Owner Name & Address: Phone Applicant Name & Address: Phone Responsible Land Disturber Name & Address: Phone RLD Cert. No.: RLD Contractor Name & Address: Phone Contractors License: Proposed Use: Residential Agricultural Timber Harvesting Commercial/Industrial Pastoral Required Attachments: Each E&S permit shall include a “to scale” plat and a minimum of 3 copies of the erosion and sediment control plans including ALL calculations and showing the following information: * Refers to the minimum standards of the VA erosion and sediment control regulations (VR 625-02-00). Please read and complete Part 2 (attached) *MS-1: Has temporary and permanent stabilization been addressed in the narrative? Are practices shown on the plan? Seed Mulch Gravel MS-2: Are stabilization of soil stockpiles addressed in the narrative? Are sediment trapping measures provided? MS-3: Has maintenance of permanent stabilization been addressed ? MS-4: Are sediment trapping facilities to be constructed as a first step in LDA ? MS-5: Has stabilization of earthen structures been addressed ? MS-6: Are sediment basins required where needed ? MS-7 & 9: Has stabilization of cut and fill slopes been adequately addressed? (ie: surface roughening, outlet protection) MS-8: Are paved flumes, channels, or slope drains required where necessary? MS-10: Is adequate inlet protection required on all operational storm sewer inlets? MS-11: Are channel lining and/or outlet protection required on storm water conveyance channels? MS-12: Are in-stream construction measures required so that channel damage is minimized ? MS-13: Are temporary stream crossings or non-erodible material required where applicable ? MS-14: (NOTE: This regulation requires that all applicable federal, state, and local regulations pertaining to working in or crossing live watercourses be followed.)? MS-15: Has re-stabilization of areas subject to in-stream construction been adequately addressed? MS-16: Is stabilization of utility trenches been addressed? MS-17: Is the transport of soil and mud onto public roadways properly controlled? MS-18: Has the removal of temporary practices been addressed? Has maintenance of practices been addressed (i.e. repair of structures and removal of accumulated sediment MS-19: Are properties & waterways from development adequately protected from erosion & sediment deposition due to increases in peak storm water runoff? Cumberland County Erosion & Sediment Application & Checklist P.O. Box 110, Cumberland, VA 23040 P: (804)492-3520 F: (804)492-9224 Date: Zoning: Tax Map Paid: Receipt ---PAGE BREAK--- PART 2 of 2: I , hereby certify that I fully understand the provisions of the Cumberland County Erosion & Sediment Control Ordinance and Program, and that I accept responsibility for carrying out the Erosion & Sediment Control Plan for the above referenced project as approved. I further grant the right-of-entry onto this property, as described above, to the designated personnel of Cumberland county for the purpose for inspecting and monitoring for compliance with the aforesaid Ordinance. The following general statements shall apply to all permits: 1. All projects shall conform to the standards and specifications and other criteria adopted by Cumberland County unless a variance has been granted in writing by this locality. 2. The issued Erosion & Sediment permit must be kept on the work site and shown on request. 3. Cumberland County must be notified when work commences and when the project is completed. 4. Other work (grading, excavating and construction) on the project shall not commence until the appropriate erosion and sediment controls are in place as specified on the plan. 5. Applicant agrees to be responsible for any and all damages to any other conservation, measures already in-place as a result of work covered by this permit. 6. Applicant agrees to maintain the conservation measures in satisfactory operating condition until final, permanent stabilization is achieved. 7. The land-disturbing permit may be revoked, should the locality determine that the project is not in compliance with the conditions of the approved plan. I , hereby certify that I have read and understand the above requirements of this permit. Signature of Owner/ Date Signature of Applicant Date Signature of Program Administrator Date Signature of Plan Approving Authority Date Cumberland County Erosion & Sediment Application & Checklist P.O. Box 110, Cumberland, VA 23040 P: (804)492-3520 F: (804)492-9224 SIGN SIGN SIGN SIGN