PERMIT NO.
Date
TOWN OF WINDSOR
ENGINEERING
275 BROAD STREET
WINDSOR, CONNECTICUT 06095
Permit Fee
Starting Date
Issued By
APPLICATION FOR PERMIT
Erosion & Sediment Control Permit
1.
PROJECT ADDRESS
Address:
Map No.
Block No.
Number of Acres to be Disturbed:
Parcel No.
(According to Town Assessor’s Map)
(Permit is required for disturbances of 0.5 acres or greater)
Copy of registration under CT DEP General Permit for the Discharge of Stormwater and Dewatering
Wastewaters Associated with Construction Activities is attached. (Required for disturbances of 5.0 acres or greater)
2.
OWNER(S) OF RECORD
Name:
Home/Mailing Address:
Telephone:
Business Address:
Telephone:
As OWNER OF THE PROPERTY I hereby authorize this Erosion & Sediment Control Permit
Application and I consent to necessary and proper inspections of the above property by agents of the
Town in accordance with the Erosion & Sediment Control Ordinance.
Dated:
, 20
Signature of PROPERTY OWNER
3.
APPLICANT
Name:
Business Address:
Check here if SAME AS OWNER
Telephone:
E-mail address:
4.
As APPLICANT I am familiar with all the information provided in this application and aware that any
permit obtained through deception, inaccurate or misleading information is subject to revocation and
penalties.
Dated:
, 20
Signature of APPLICANT
PROFESSIONAL ENGINEER
Name:
Business Address:
Telephone:
E-mail address:
5.
INDIVIDUAL RESPONSIBLE FOR MONITORING E&S CONTROL MEASURES
Name:
Business Address:
Daytime Telephone:
Nighttime/Emergency Telephone:
TOWN OF WINDSOR
ENGINEERING
275 BROAD STREET
6.
EROSION AND SEDIMENT CONTROL PERMIT APPLICATION
ON-SITE MONITOR OF E&S CONTROL MEASURE INSTALLATION AND MAINTENANCE
Name:
Business Address:
Daytime Telephone:
Nighttime/Emergency Telephone:
7.
NATURAL RESOURCES MAP
8.
SITE PLAN
Check here if submitted with application to Planning and Zoning Department as part of separate
application for Site Plan Approval, Subdivision Application, or Special Use Permit.
On a scaled site plan prepared by a Connecticut Licensed Professional Engineer, show the following:
a.
Proposed area alterations including cleared, excavated, filled, or graded areas.
b.
Location and design details of all proposed soil erosion and sediment control measures and storm
water management facilities.
c.
Sequence of grading and construction activities, and installation and/or typical application of soil
erosion and sediment control measures.
d.
9.
Soil types listed in tabular form and shown on plan.
SOIL EROSION AND SEDIMENT CONTROL DATA
Shown on SITE PLAN, or
Described in SEPARATE ATTACHMENT
In narrative format, describe the following:
a.
Proposed soil erosion and sediment control measures.
b.
Phasing plan, if applicable.
c.
Schedule of grading and construction activities including the sequence for installation and/or
application of soil erosion and sediment control measures and final stabilization of the site. Include start
and stop dates as well as duration of activity.
d.
Installation and/or application procedures as well as operation and maintenance programs for soil
erosion and sediment control measures (including identification of person(s) responsible for each
procedure or program).
f.
Provisions for control of waste at the site including, but not limited to, discarded building materials,
concrete truck washout, chemicals, litter, and sanitary waste.
g.
Contingency provisions. Describe your procedures if unforeseen erosion or sedimentation problems
arise.
The APPLICANT understands and agrees that any land clearing, construction, or development involving the movement of earth shall be
in accordance with the Erosion and Sediment Control Plan.
Applicant’s Signature
Date
Owner’s Signature
Date
Received by (Name of Engineering Representative):
c: Town Planner
Building Official
Environmental Planner
Construction Inspector