For Office use only:

LAND DISTURBANCE PERMIT APPLICATION

Approved Approved with Conditions * Denied *

For Office use only:

PERMIT # ___________ Address of Site:

By: __________________________ Date: ____ / ____ / ______ * See attached documentation

______________________

______________________ ______________________

Date of Application: ____/____/_____

Name and address of responsible party*:

Name and address of applicant*: (If different than responsible party)

________________________________

________________________________

________________________________

________________________________

________________________________

________________________________

________________________________

________________________________

Telephone number: ______-______-______

Telephone number: _____-______-_______

Signature of the responsible party of the site or authorized representative per 401 KAR 5:065, Section 1(11)*:

(PRINTED NAME)

(SIGNATURE)

(DATE)

Name(s), address(es), of contractors, subcontractors, or person actually doing the land disturbing or land filling activities and their respective tasks (Attach separate sheet if needed). ___________________________________ ___________________________________

____________________________________ ____________________________________

___________________________________

____________________________________

___________________________________

____________________________________

Telephone number: _____-______-______ Task:_______________________________ ___________________________________

Telephone number: _____-______-_______ Task:________________________________ ____________________________________

Name and address of person responsible for preparation of the SWPPP*. ______________________________ ______________________________ ______________________________

Telephone number: ______-______-_______

______________________________

Name and address of qualified inspector(s)* assigned to construction activity. Provide proof of training or certification. _______________________________ Telephone number: ______-_______-_______ _______________________________ _______________________________ _______________________________ Estimate of total construction and maintenance costs for EPSC measures (TIER II SWPPP*). ________________ *Refer to Georgetown/Scott County’s Erosion Prevention and Sediment Control Ordinance effective September 1, 2010. Instructions for the Land Disturbance Permit Application are located at http://www.georgetownky.gov/content/view/43/34/.

LAND DISTURBANCE PERMIT APPLICATION INSTRUCTIONS Important reference documents for the Land Disturbance Permit Application include: o City of Georgetown & Georgetown/Scott County Planning Commission’s Erosion Prevention and Sediment Control Ordinance (effective September 1, 2010); o KPDES General Permit for Stormwater Discharges Associated with Construction Activities (effective June 29, 2009); and o Kentucky Erosion Prevention and Sediment Control Field Guide. The Land Disturbance Permit Application is available at http://www.georgetownky.gov/content/view/43/34/. The application may be picked up at any of the locations listed below, which is where the completed applications may also be submitted. PLANNING COMMISSION ATTN: Staff Engineer 230 East Main Street Georgetown, KY 40324 P – 502.867.3701 F – 502.867.3725

CITY ENGINEER ATTN: City Engineer 100 North Court Street Georgetown, KY P – 502.867.2000

BUILDING INSPECTION DEPARTMENT ATTN: Chief Building Inspector 100 North Court Street Georgetown, KY P – 502.863.9802 F – 502.863.4169

Payment of permitting fees is due upon submittal of the completed Land Disturbance Permit Application. For application fees see the “Schedule of Fees” attached to the Erosion Prevention and Sediment Control Ordinance (effective September 1, 2010). Site inspections shall be performed by the Georgetown Stormwater Quality Division (GSQUAD). The associated fees with the permit application will be collected by the respective agency listed above that is accepting the permit application. Checks shall be made out to the following agency depending upon submittal location: o Planning Commission – “Georgetown-Scott County Planning Commission” o City Engineer – “City of Georgetown” o Building Inspection – “Georgetown-Scott County Building Inspection” For TIER II SWPPPs, NOIs must be sent to the Kentucky Division of Water (KDOW) at the following address: Section Supervisor Permit Support Section Surface Water Permit Branch, KDOW Frankfort Office Park 200 Fair Oaks Lane, 4th Floor Frankfort, KY 40601 For questions regarding the NOI application, please contact Larry Sowder (KDOW) at 502.564.3410. Applicants are strongly encouraged to submit an eNOI-SWCA, located at: https://dep.gateway.ky.gov/eForms/default.aspx?FormID=7. Example Filing Scenarios: o Completing the addition of an existing structure and disturb 4,400 SF. You do not need a Land Disturbance Permit. o Completing a new structure that disturbs 4,000 SF that is adjacent to a critical area. Submit the Land Disturbance Permit and the TIER II SWPPP. o Building a new house that disturbs 6,500 SF. The lot is in a common plan of development that is currently covered under a KPDES NOI and the SWPPP has single lot perimeter controls as part of the plan. Submit the Land Disturbance Permit and the TIER I SWPPP. o Building a new house that disturbs 9,000 SF and is not located near a critical area. Submit the Land Disturbance Permit and the TIER I SWPPP. o Building a new house that disturbs 8,000 SF and is located near a critical area. Submit the Land Disturbance Permit and the TIER II SWPPP. o Developing 5 acres. Submit Land Disturbance Permit and TIER II SWPPP. The Land Disturbance Permit is to address Stormwater Quality Issues associated with discharging into the City of Georgetown’s stormwater system. It does not replace other local permits that may be necessary for your construction.

Stormwater Inspection Report for Tier II Construction Sites Project Name: _______________________________

Date of Inspection: ______________ KPDES#: ____________

Land Disturbance Permit No. _____________

Project Start Date: ____________

Date of Preconstruction Meeting? ______________ Type of Inspection:

Permitee*:

Weekly

Post-storm event (greater than 0.5 inches in 24hr. period)

Georgetown:

Planning Commission

City Engineer

Inspector Name: ______________________________ Date of recent storm event __________

Amount of Rain ________ Inches

Were changes made to SWPPP since last inspection?

Yes

Stage of Construction (% complete) __________%

No

Overall Site Issues BMP/activity

Implemented?

Maintenance Required?

1

Are all slopes and disturbed areas not actively being worked (14 days or more) properly stabilized?

Yes No

Yes No

2

Are natural resource areas (e.g., streams, wetlands, mature trees, etc.) protected with barriers or similar BMPs?

Yes No

Yes No

3

Are perimeter controls and sediment barriers adequately installed (keyed into substrate) and maintained?

Yes No

Yes No

4

Are discharge points and receiving waters free of any sediment deposits?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Corrective Action Needed and Notes

Are storm drain inlets properly protected? 5

6

7

8

9

10

Is the construction exit preventing sediment from being tracked into the street? Is trash/litter from work areas collected and disposed of properly to avoid contamination of stormwater runoff? Are washout facilities (e.g., paint, stucco, concrete) available, clearly marked, and maintained? Is site free of spills, leaks, or any other deleterious material from equipment fueling, cleaning and maintenance? Are materials that are potential stormwater contaminants stored inside or under cover?

Georgetown EPSC Tier II Inspection Report

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BMP/activity

11

Are non-stormwater discharges (e.g., wash water, dewatering) properly controlled?

BMP Description (List all BMP’s on plan or added in field)

BMP Installed & Operating properly?

Implemented?

Maintenance Required?

Yes No

Yes No

Corrective Action Needed and Notes

Corrective Action Needed? (If No is checked, specify action needed in space provided)

Date of corrective action/responsible person

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

Comments:__________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ *Certification Statement for Permitee “I hereby certify under penalty of law that by signing as the On Site Contractor Representative, the installation & maintenance of all erosion & sediment control BMP’s, and the completion of the Stormwater Construction Site Inspection Report will be performed by me or by an EPSC inspector under my direction and supervision and the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are penalties and fines for submitting false information, including the possibility of revoking my Land Disturbance Permit.” Signature: _________________________________________________________ Date:_____________________

BELOW LINE FOR GEORGETOWN USE ONLY

Enforcement Action Required? If Yes, Type of Enforcement:

Yes

No

Notice of Violation (NOV)

Georgetown EPSC Tier II Inspection Report

Stop Work Order (SWO)

Second SWO

Permit Revocation

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Stormwater Inspection Report for Tier II Construction Sites Notes for Permitee: 

All pages of this inspection report along with the Land Disturbance Permit (LDP), Stormwater Pollution Prevention Plan(SWPPP), and Notice of Intent (if applicable) must remain on site during construction activities and made available to the Georgetown inspector upon request.



This report is to be used for each inspection. Each BMP shown on the SWPPP must be inspected and noted by the Permitee ’s Erosion Control Inspector within 24 hours of a half inch or greater storm event and every 14 calendar days or every 7 days.



All repairs and maintenance should be completed within 5 days from the date of inspection unless otherwise informed.



Any BMP deletions from the approved plan must be redlined and approved by Georgetown (GSQUAD).



Adding to or extending an approved BMP must be marked on plan and shown to the Georgetown Inspector.



Refer to the “Kentucky Erosion Prevention and Sediment Control Field Guide” for guidance on inspecting specific BMP’s.



Carry a copy of this report and plans with you during your inspections to ensure that you are inspecting all required BMP’s on your site



Enforcement Escalation Per Georgetown’s Erosion Prevention and Sediment Control Ordinance effective as of September 1, 2010: 1. 2. 3. 4. 5.

Notice of Violation (NOV) with a five (5) day correction period First Stop Work Order (SWO) with a $50 fine and a 5 day correction period Second SWO with a $100 fine and permit revocation Six (6) days after the Second SWO Georgetown will post a notice of intent to perform the work Abatement after 14 days of posting notice of intent. Failure to reimburse the City within 30 days will result in a lien on the property

Georgetown EPSC Tier II Inspection Report

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