BURLINGTON BOARD OF HEALTH
61 Center Street
Burlington, MA 01803
Tel: 781-270-1955 Fax: 781-273-7687
Stormwater and Runoff Management Plan Submittal Form
Applicant Information
Name of Applicant:
Date:
Contact Name/Title:
Mailing Address:
Phone:
Email:
Business Owner Information
Name of Business Owner/Title:
Mailing Address:
Name of Person Completing Form:
Phone:
Email:
Property Owner Information
Name of Property Owner:
Mailing Address:
Phone::
Conservation Commission/Department Review:
Type of review or permit requested:
Status of Application:
Yes ☐ No ☐
Planning Board/Department Review:
Type of review or permit requested:
Status of Application:
Yes ☐ No ☐
Are there known or suspected areas of
contamination on the property or in the area?:
If yes, provide a description:
Yes ☐ No ☐
Project Narrative and Description of Stormwater Control and Management (at a minimum, this section must
contain a description of the project, how stormwater will be controlled, and sedimentation & erosion control. A site
plan showing existing and proposed conditions must be attached.):
CERTIFICATION
☐ By checking this box, I hereby certify that the Stormwater and Runoff Management Plan for this project has
been designed to accomplish the following goals:
A. Mitigate the effects of increased stormwater runoff onto public streets and adjacent private
property due to development or re-development.
B. Reproduce, as nearly as possible, the hydrogeologic conditions in the ground and surface
waters prior to development or re-development;
C. Have an acceptable operation and management plan;
D. Have a neutral effect on the natural and human environment;
E. Be appropriate for the site, given physical restraints;
F. Provide a sufficient level of health and environmental protection during the construction
phase.
G. Provide a sufficient level of protection to maintain the safety and quality of life of residents
as well as the protection of property.
Signature of Applicant
Date
Signature of Property Owner
Date