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Engineering Approval: Storm Water Dept. Approval: APPLICATION FOR LAND DISTURBANCE PERMIT $100 Permit Fee Project Name: Date: Project Location: Land Owner: Phone: ( ) Email: Address: City State ZIP Code Preparer: Phone: ( ) Email: Manager: Phone: ( ) Email: Address: City State ZIP Code Area of land disturbance (acres): Zoning: I certify that I am authorized by the owner of the above referenced property to perform the work as indicated on the site plan as approved by the City of Murray. I certify that I will perform the excavation at the indicated locations as shown on the site plan. I also certify that I am the responsible land disturber and accept responsibility for installing and maintaining on site, all erosion control and stormwater control measures as approved by the City. I certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing work will be complied with whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel any State or local law. I make this statement under penalty of perjury Applicant Name (Print): Applicant Signature: Date: ---PAGE BREAK--- COMPLETION and PRECONSTRUCTION CHECKLIST The City will not accept as a notes placed on a set of site development plans. The must contain the following checklist information and be submitted to the City, in bound notebook form, for review prior to demolition/construction. A copy of the must remain onsite during construction and until a Notice of Termination (NOT) is filed with the State. □ Letters of certification of responsibility for the preparation, information, review and maintenance of the from the: □ Owner □ Contractor/Operator □ Engineer □ Letters from the Owner delegating for the site a qualified storm water inspector and a qualified BMP installer and maintainer. □ Description of the site including but not limited to: □ Location – address, latitude and longitude □ Contact information (address, phone number, email) for all responsible parties involved with and certifying the such as Owner, Project Engineer, Contractor, Site Supervisor, Subcontractor, Consultant, inspector, etc. □ Start and completion dates □ Description of site size, size of disturbed area, soil types, vegetation, slopes, drainage patterns, potential pollution sources, receiving waters, sensitive areas □ Hydrologic information including: □ rainfall data □ pre- and post-construction runoff coefficient □ hydraulic calculations for runoff, storage, piping, etc. Refer to the Murray City Storm Water Guidance Manual Chapter 2 for hydraulic design standards. □ Nature and sequence of activities and BMP’s to be applied at each stage of construction □ Schedule of construction activities and description of land disturbance activities □ Sensitive areas – wetlands, impaired waters, high quality waters, historic sites □ Site maps (half sized) must be included in the and are to contain: □ Vicinity map with the site location □ Existing conditions including: □ property lines □ dimensions and bearings of the property, buildings □ contour lines at 1 foot intervals □ scale of 1inch to 20 feet □ existing buildings, structures □ roads, easements, utilities on both the property and within 50 feet of the boundary □ drainage systems, vegetation ---PAGE BREAK--- □ Construction map showing on the site: □ Roads □ Cuts, fills □ Contours before and after grading, flow arrows □ Disturbed areas □ Location and type of BMP’s identified in the site description □ Locations and type of interim stabilization □ Waste, borrow, equipment storage areas □ Site entrance details □ Traffic control plan □ Updated map as each phase of construction is completed □ Other Controls □ Waste disposal □ Offsite tracking and dust control □ Waste and sewage location and control □ Vehicle/equipment maintenance areas and controls □ Construction materials storage and controls □ Inspection and Maintenance Plan □ Include inspection schedule minimum of once every 7 days, or every 14 days and within 24 hrs after a storm of 0.5 inches or greater □ Inspection report to include: □ date, name and title of inspector □ Inspector qualifications □ weather information □ BMP locations needing maintenance □ location where additional BMPS are needed □ location of pollutant discharges □ any corrective actions taken □ A final site map showing the completed site including: □ Contours, flow arrows □ Roads, buildings □ Locations and type of final stabilization □ Storm drain inlets, outfall location(s) and name of receiving waters □ All structural BMP’s □ Post construction BMP’s □ Description of how pollutants are controlled after construction □ Justification for choosing post construction BMP’s □ Description and technical justification of flow diversion BMP’s □ Description and technical justification of flow storage BMP’s □ Maintenance requirements and schedules □ Low Impact Development Design – Include consideration of any LID concepts for the project □ Copy of NOI submitted to the State □ Copy of the current General Permit for Construction Activities