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g:\data\dbases\forms\permit\word\erosioncontrollanddistpermit2012-11-14.docx 1 of 2 11/15/2012 EROSION CONTROL/LAND DISTURBING PERMIT APPLICATION & CHECKLIST CITY OF MIDDLETON 7426 HUBBARD AVE., MIDDLETON, WI 53562 [PHONE REDACTED] FAX [PHONE REDACTED] Area = S.F. Project Address Project Name and Description Applicant Address Phone Landowner Address Phone Plan prepared by I, hereby certify that I fully understand the provisions of the City of Middleton Erosion and Sediment Control Ordinance and Program, and that I accept responsibility for carrying out the Erosion and Sediment Control Plan for the above-referenced project as approved by the City. I further grant the right-of-entry onto this property, as described above, to the designated personnel of the City of Middleton for the purpose of inspecting and monitoring for compliance with the aforesaid Ordinance. I certify that all information is correct and that all pertinent City Ordinances will be complied with in performing the work for which this permit is issued. Landowners of construction sites with one or more acres of land disturbance including commercial building sites, need to obtain storm water construction site permit from the Department of Natural Resources pursuant to subch. III of ch. NR 216, Wis. Adm. Code. DNR application forms and supporting information are available at: DNR's storm water program contact is Eric Rortvedt (273-5612; [EMAIL REDACTED]). Signature of Applicant Print Name Date APPROVED: City of Middleton Official Date Dane County Land Conservation 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. Any unpaid charges shall be assessed to the subject property as a special charge pursuant to Wis. Stats. 66.0627 and placed on the tax roll. Permit Permit Effective Date Permit ---PAGE BREAK--- g:\data\dbases\forms\permit\word\erosioncontrollanddistpermit2012-11-14.docx 2 of 2 11/15/2012 EROSION CONTROL APPLICATION CHECKLIST Erosion Control Plan Requirements – Plan Materials X Location of Information: Page Number or Attachment 1. Narrative describing the proposed project 2. Site plan (of known scale that includes: property lines, disturbed area limits, impervious area limits (existing and proposed), natural and artificial water features, 100-yr flood plain, delineated wetland boundaries, location of all proposed erosion control practices) NOTE: Grading within 5' of the property line requires department approval 3. Contours (existing and proposed) 4. Watershed size for each drainage area (include area draining to the site and within project boundaries) 5. Culvert sizes (existing and proposed) 6. Cross sections and profiles of ditches, channels, swales and structural measures (existing and proposed) 7. Design calculations for ditches, channels, swales and structural measures (velocity & capacity calculations) 8. Direction of runoff flow from impervious surfaces (roof downspouts, driveways, etc.) 9. Universal Soil Loss Equation (USLE) worksheet(s) (for each element of the erosion control plan. Dates must correspond to construction schedule and be appropriate for each erosion control practice) 10. Tracking control (provisions to prevent mud-tracking onto public streets and roads during construction, e.g. tracking pad or existing gravel drive) 11. Sediment control practices to protect storm water facilities or storm sewer inlets, existing and proposed, on or adjacent to the site (e.g. inlet protection or stone weeper) 12. Site stabilization details & methods (type & rate of fertilizer, seed, mulch, sod, etc.) 13. Any other necessary information pertaining to the physical or environmental features of the site Erosion Control Plan Requirements - Performance Standards X Location of Information: Page Number or Attachment 14. Prevent gully and bank erosion 15. Practices must reduce erosion to minimum sheet and rill erosion standards: (7.5 tons/acres/year) 16. Proof of stable outlet capable of carrying site runoff at a non-erosive velocity (outlet design must account for flow capacity and duration) Permit Application Requirements X Location of Information: Page Number or Attachment 17. Timetable and construction schedule 18. Copies of permits or approval from other agencies (WDNR, US Army Corps of Engineers, County Zoning, Town, etc.) 19. Itemized estimated cost of erosion control plan implementation (including installation and labor)