DEQ USE ONLY
File #:
Application #:
LLID #:
River Mile:
Legal Name Confirmed: [ ]
Notes:
SMALL LOT APPLICATION
NPDES GENERAL PERMIT #1200-C
For stormwater discharges to surface waters from construction activities disturbing less than one acre that are part of a common plan of development disturbing one or more acres. Sites that meet the automatic coverage requirements of the 1200-CN permit are not required to submit this application.
DEQ USE ONLY
Date Received:
Amount: $
Check Name:
Check #:
Deposit #:
Receipt #:
Notes:
PLEASE ANSWER ALL QUESTIONS COMPLETELY
A. PROJECT INFORMATION
1. Applicant (Owner, Developer, or General Contractor):
2. Name of Subdivision or Commercial/Industrial Park:
Contact Name (if different than applicant)
Approximate location of center of site: *
Address
Latitude:
Longitude:
City/State /Zip
Total Site Acreage (acres):
Total Disturbed Area (acres):
Telephone
*For assistance: Location Tool at:
Email Address
3. Site location:
4. Nature of Construction Activity:
[ ] Single Family (SIC Code 1521)
[ ] Multi-Family Residential (SIC Code 1522)
[ ] Commercial (SIC Code 1542)
[ ] Industrial (SIC Code 1541)
Address or Cross Street
City/ State/ Zip
County
5. Stormwater runoff during construction will flow to:
[ ] Creek/Stream (provide name):
[ ] Ditch (provide name of receiving stream for ditch):
[ ] Municipal storm sewer or drainage system (provide name of receiving stream for system):
B. SIGNATURE OF LEGALLY AUTHORIZED REPRESENTATIVE
I hereby certify that the information contained in this application is true and correct to the best of my knowledge and belief. In addition, I agree to pay all permit fees required by Oregon Administrative Rules 340-045.
Name of Legally Authorized Representative
(Type or Print)
Title (if applicable)
Signature of Legally Authorized Representative
Date