DEQ USE ONLY
File #:
Application #:
LLID/RM:
River Mile:
Legal Name Confirmed: [ ]
Notes:
DEPARTMENT OF ENVIRONMENTAL QUALITY
APPLICATION FOR NEW
NPDES GENERAL PERMIT 1200-C
For stormwater discharges to surface waters from construction activities disturbing one acre or more that do not meet automatic coverage requirements.*
DEQ USE ONLY
Date Received:
Amount: $
Check Name:
Check #:
Deposit #:
Receipt #:
Notes:
*A project may be eligible for “automatic coverage” under NPDES general permit 1200-CN if stormwater does not discharge to a water body with a TMDL or 303(d) listing for sediment or turbidity and it meets one of the following criteria (see 1200-CN at http://www.deq.state.or.us/wq/wqpermit/docs/general/npdes1200cn/1200CNPermit.pdf):
1) Disturbs less than one acre and is located in Gresham, Troutdale, or Wood Village.
2) Disturbs less than five acres and is located in Albany, Corvallis, Eugene, Milwaukie, Multnomah Co. (unincorporated areas), Springfield, West Linn, or Wilsonville.
3) Disturbs less than five acres and is within the jurisdictions of Clackamas Co. Water Environment Services [Gladstone, areas within Clackamas Co. Service Dist. #1 (excluding Happy Valley), and areas within the Surface Water Management Agency of Clackamas Co. (including Rivergrove)], Clean Water Services (Banks, Beaverton, Cornelius, Durham, Forest Grove, Hillsboro, King City, North Plains, Sherwood, Tigard, Tualatin, and Washington Co. within Urban Growth Boundary), or Rogue Valley Sewer Services (Central Point, Phoenix, Talent, and portions of Jackson Co. in NPDES MS4 permit area).
Please answer all questions.
A. PROJECT INFORMATION
1.
Applicant (entity legally responsible for permit)
Contact Name (if different from applicant)
Address
City State Zip
Telephone E-Mail Address
2. Invoicing information (person or entity legally responsible for payment of annual fee invoice; not a third party independent of the applicant)
Invoice Contact Name (if different from applicant)
Address
City State Zip
Telephone E-Mail Address
3.
Architect/Engineering Firm (Erosion & Sediment Control Plan)
Project Manager
Telephone E-Mail Address
4.
Applicant's Designated Erosion and Sediment Control Inspector
Company Name
Telephone E-Mail Address
5.
Name of Project
Address or Cross Street
City State Zip
County
6. Nature of Construction Activity
[ ] Single Family (SIC Code 1521)
[ ] Multi-Family Residential (SIC Code 1522)
[ ] Commercial (SIC Code 1542)
[ ] Industrial (SIC Code 1541)
[ ] Highway (SIC Code 1611)
[ ] Utilities (SIC Code 1623):
[ ] Other (include SIC Code):
7. Approximate location of center of site:
Latitude:
Longitude:
**For assistance: DEQ Location Tool at http://deqgisweb.deq.state.or.us/llid/llid.html**
8. Project Size:
Total Site Acreage (acres):
Total Disturbed Area (acres):
9. Stormwater runoff during construction will flow to:
[ ] Infiltration device(s)
[ ] 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):
[ ] Other:
10. Stormwater runoff during construction discharges directly to or through a storm sewer or drainage system that discharges to a water body with a Total Maximum Daily Load (TMDL) or 303(d) listing for turbidity or sedimentation? [ ] YES [ ] NO
**For assistance: DEQ Lookup Tool at http://deq12.deq.state.or.us/tmdl/default.aspx or
DEQ Map/Table at http://deq12.deq.state.or.us/tmdl/default.aspx**
B. LAND USE COMPATIBILITY STATEMENT
Submit a DEQ Land Use Compatibility Statement (LUCS) form that has been completed by the local land use authority with this application. Attach the original LUCS and, if applicable, written findings by the local authority. DEQ will not process the application unless the local land use authority indicates on the LUCS form that the project is compatible with the local acknowledged comprehensive plan and land use regulations.
**A copy of this form may be found at http://www.deq.state.or.us/pubs/permithandbook/generallucs.pdf**
C. SIGNATURE OF LEGALLY AUTHORIZED REPRESENTATIVE
The legally authorized representative must sign the application.
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. This includes a compliance determination fee invoiced annually by DEQ to maintain the permit.
Name of Legally Authorized Representative (Type or Print)
Title
Signature of Legally Authorized Representative
Date
APPLICATION AND FEE SUBMITTAL
To authorize permit registration, the following must be completed and submitted to the appropriate DEQ regional office or DEQ Agent (see list of offices in application instructions, pp. 3-4):
[ ] DEQ application form signed by the Legally Authorized Representative and meeting the signature requirements below.
[ ] DEQ LUCS by local land use authority indicating the activity is compatible with local acknowledged comprehensive plan and land use regulations. Include the Findings if so stated on the LUCS.
[ ] Stormwater Erosion and Sediment Control Plan Narrative, if applicable.
[ ] Stormwater Erosion and Sediment Control Plan Drawings; full-sized hard copy and electronic PDF files.
[ ] Effective 11/1/13, the fee for a new application is $1,676 payable to Oregon DEQ and you must submit it with this application. Please note that DEQ will also invoice you for an annual fee of $850 if your project needs permit coverage for more than a year. These fees are subject to change; please visit http://www.deq.state.or.us/wq/wqpermit/stminfo.htm for current fees. If you are sending your application to a DEQ Agent, check with the DEQ Agent for appropriate fees and make check payable to the DEQ Agent.