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G:\Data\DBases\Forms\Permit\Word\StormWaterRunoffControlPermitAppChecklist_2018-11-05.doc 1 of 4 STORM WATER RUNOFF CONTROL PERMIT APPLICATION & CHECKLIST CITY OF MIDDLETON 7426 HUBBARD AVE., MIDDLETON, WI 53562 [PHONE REDACTED] • FAX [PHONE REDACTED] Project Address Project Name and Description Parcel ID No. Pre-Existing Impervious Area = S.F. New Impervious Area = S.F. (constructed prior to 08/22/2001) (proposed, this project) Existing Impervious Area = S.F. Other Land Disturbance Area = S.F. (constructed after 08/22/2001) (existing pervious or impervious, disturbed this project) APPLICANT LANDOWNER PLAN PREPARER Name Address Phone Email ATTACHMENTS Plan Submittal Checklist Site and Grading Plans, including final revisions Storm Water Calculations (.pdf file and a hard copy of the approved plan Recorded Maintenance Agreement must be submitted to the City of Middleton) I, hereby certify that all information herein and attached hereto is correct, that I fully understand the provisions of the City of Middleton Storm Water Runoff Control Ordinance and Program, and that I accept responsibility for carrying out the Storm Water Runoff Control Plan, in full compliance with all pertinent City Ordinances, for the above-referenced project as approved by the City. I understand that the Permit Application Fee is non-refundable and must be paid at the time of permit submittal. I further acknowledge on behalf of the landowner that the City of Middleton has the right to designate personnel to enter the project premises for the purpose of inspecting and monitoring for compliance with the aforesaid Ordinance. Per City Ordinance 26.10(7)(d), Permit Applicant or designated agent must contact a representative of Dane County Land Conservation, as agent of the City Engineer, at least two business days prior to installation of storm water management practices. Said representative must be present during construction. Signature of Applicant Print Name Date APPROVED: City of Middleton Official Date Dane County Land Conservation Division Official Date Date paid Receipt # Permit Fee $250.00 Permit fee must be paid before Dane County review will begin. In addition to the permit fee, the applicant shall pay the actual costs incurred by the City from any consultants or agents with whom the City may contract to provide services relating to the administration of this Code. The City shall bill the applicant for such charges, which shall be paid within 30 days, after which time a 1.5% fee will be added. Any unpaid charges shall be assessed to the subject property as a special charge pursuant to Wis. Stats. 66.0627 and placed on the property tax roll. Permit # Permit Effective Date ---PAGE BREAK--- G:\Data\DBases\Forms\Permit\Word\StormWaterRunoffControlPermitAppChecklist_2018-11-05.doc 3 of 4 STORM WATER MANAGEMENT APPLICATION CHECKLIST Storm Water Plan Requirements – Plan Materials X Location of Information (Page, Appendix, or Exhibit Number) 1. Narrative describing the proposed project 2. Identification of the entity responsible for long-term maintenance of all Storm Water management facilities and practices 3. Map of drainage areas for each watershed (showing assumed time of concentration flow path) 4. Storm Water runoff control calculations and summary tables * for peak flow, TSS, infiltration/ recharge. 5. Complete site plan and grading plans, and specifications * 6 Engineered designs for all structural management practices (reference relevant technical standard if appropriate) 7. Description of methods to control oil and grease (see Dane County Erosion Control and Storm Water Management Manual) http://www.countyofdane.com/lwrd/landconservation/ 8. Provisions and practices to reduce the temperature of runoff (required for sites that drain to a cold water community, as identified in the ordinance – see Thermal Locator) http://www.countyofdane.com/lwrd/landconservation/ 9. Maintenance plan and schedule for all permanent Storm Water management practices Storm Water Plan Requirements - Performance Standards X Location of Information (Page, Appendix, or Exhibit Number) 10. Reduce TSS by 80% (new development) and 40% (redevelopment) for the 1-year, 24-hour storm event. 11. Treat first ½ inch of runoff for oil and grease 12. For new development, maintain peak discharge rates for the 1, 2, 5, 25 and 100-year 24-hour storm events, (new development) and for the 1, 2, 5, and 10-year 24-hour storm events (redevelopment) 13. Provide proof of stable outlet capable of carrying site runoff at a non-erosive velocity (outlet design must account for flow capacity and duration) 14. Infiltrate 90% of the predevelopment infiltration volume 15. Provide recharge to meet or exceed average annual predevelopment rate 16. Provide runoff temperature control within watersheds of thermally sensitive rivers and streams Permit Application Requirements X Location of Information (Page, Appendix, or Exhibit Number) 17. Draft storm water management maintenance agreement 18. Copies of permits or approvals from other agencies (WDNR, US Army Corps of Engineers, Dane County Land Conservation, Town, etc.) 19. Timetable and construction schedule 20. Itemized cost estimate for storm water plan implementation 21. Financial responsibility (financial security instrument required if cost estimate exceeds $5000) * See Notes for detailed requirements on next page Upon completion of the project, applicant shall submit written certification (e.g. record drawings) by a registered State of Wisconsin Professional Engineer that the storm water management practices have been installed in accordance with the approved plan and all applicable provisions of Chapter 26 of the Municipal Code. ---PAGE BREAK--- G:\Data\DBases\Forms\Permit\Word\StormWaterRunoffControlPermitAppChecklist_2018-11-05.doc 4 of 4 The summary table in Storm Water Plan Requirements - Plan Materials, Item #4 must include the following: a. pre-existing peak flow rates b. post construction peak flow rates with no detention c. post construction peak flow rates with detention d. assumed runoff curve numbers e. time of concentration used in calculations Complete site plan and specifications in Storm Water Plan Requirements - Plan Materials, Item # 5 must include the following: a. property lines and lot dimensions b. all buildings and outdoor uses, existing and proposed, including all dimensions and setbacks c. all public and private roads, interior roads, driveways and parking lots, showing traffic patterns and type of paving and surfacing material d. all natural and artificial water features e. depth to bedrock f. depth to seasonal high groundwater table g. the extent and location of all soil types as described in the Dane County Soil Survey, slopes exceeding 12%, and areas of natural woodland or prairie h. existing and proposed elevations i. elevations, sections, profiles, and details as needed to describe all natural and artificial features of the project j. soil erosion control and overland runoff control measures, including runoff calculations as appropriate k. detailed construction schedule l. copies of permits or permit applications required by any other governmental entities or agencies m. any other information necessary to reasonably determine the location, nature and condition of any physical or environmental features n. all existing and proposed drainage features o. the location and area of all proposed impervious surfaces p. the size (square feet) and extent (limits) of the disturbed area STORM WATER MANAGEMENT APPLICATION CHECKLIST NOTES