BFDF_-_NOI_rev 1 .pdf

New York State Department of Environmental Conservation

Division of Water

625 Broadway, 4th Floor

Albany, New York 12233-3505

NOTICE OF INTENT

All sections must be completed unless otherwise noted. Failure to complete all items may result in this form being returned to you, thereby delaying your coverage under this General Permit. Applicants must read and understand the conditions of the permit and prepare a Stormwater Pollution Prevention Plan prior to submitting this NOI. Applicants are responsible for identifying and obtaining other DEC permits that may be required.

-IMPORTANT-

RETURN THIS FORM TO THE ADDRESS ABOVE

OWNER/OPERATOR MUST SIGN FORM

Stormwater Discharges Associated with Construction Activity Under State Pollutant Discharge Elimination System (SPDES) General Permit # GP-0-10-001

Owner/Operator Information

Owner/Operator Contact Person Last Name (NOT CONSULTANT)

Owner/Operator Contact Person First Name

Owner/Operator Mailing Address

City

State Zip

Phone (Owner/Operator)

Fax (Owner/Operator)

Email (Owner/Operator)

Owner/Operator (Company Name/Private Owner Name/Municipality Name)

NYR

(for DEC use only)

FED TAX ID

- (not required for individuals)

1358331598

1. Provide the Geographic Coordinates for the project site in NYTM Units. To do this you must go to the NYSDEC Stormwater Interactive Map on the DEC website at:

www.dec.ny.gov/imsmaps/stormwater/viewer.htm

Zoom into your Project Location such that you can accurately click on the centroid of your site. Once you have located your project site, go to the tool boxes on the top and choose "i"(identify). Then click on the center of your site and a new window containing the X, Y coordinates in UTM will pop up. Transcribe these coordinates into the boxes below. For problems with the interactive map use the help function.

X Coordinates (Easting) Y Coordinates (Northing)

Project Site Information

Project/Site Name

Street Address (NOT P.O. BOX)

City/Town/Village (THAT ISSUES BUILDING PERMIT)

State Zip

County

Name of Nearest Cross Street

Distance to Nearest Cross Street (Feet) Project In Relation to Cross Street

North South East West

2. What is the nature of this construction project?

New Construction

Redevelopment with increase in imperviousness

Redevelopment with no increase in imperviousness

Section-Block-Parcel Tax Map Numbers

Side of Street

North South East West

DEC Region

Tax Map Numbers

1863331599

3. Select the predominant land use for both pre and post development conditions.

SELECT ONLY ONE CHOICE FOR EACH

8. Do you plan to disturb more than 5 acres of soil at any one time?

9. Indicate the percentage of each Hydrologic Soil Group(HSG) at the site.

Existing Land Use

FOREST

PASTURE/OPEN LAND

CULTIVATED LAND

SINGLE FAMILY HOME

SINGLE FAMILY SUBDIVISION

TOWN HOME RESIDENTIAL

MULTIFAMILY RESIDENTIAL

INSTITUTIONAL/SCHOOL

INDUSTRIAL

COMMERCIAL

ROAD/HIGHWAY

RECREATIONAL/SPORTS FIELD

BIKE PATH/TRAIL

LINEAR UTILITY

PARKING LOT

OTHER

Future Land Use

SINGLE FAMILY HOME

SINGLE FAMILY SUBDIVISION

TOWN HOME RESIDENTIAL

MULTIFAMILY RESIDENTIAL

INSTITUTIONAL/SCHOOL

INDUSTRIAL

COMMERCIAL

MUNICIPAL

ROAD/HIGHWAY

RECREATIONAL/SPORTS FIELD

BIKE PATH/TRAIL

LINEAR UTILITY (water, sewer, gas, etc.)

PARKING LOT

CLEARING/GRADING ONLY

DEMOLITION, NO REDEVELOPMENT

WELL DRILLING ACTIVITY *(Oil, Gas, etc.)

OTHER

Yes No

Pre-Development Post-Development

4. Will future use of this site be an agricultural property as defined by the NYS Agriculture and Markets Law ? Yes No

Yes No

5. Is this a project which does not require coverage under the General

Permit (e.g. Project done under an Individual SPDES Permit, or department approved remediation)?

Yes No

6. Is this property owned by a state authority, state agency, federal government or local government?

A B C D

Number of Lots

Total Site Acreage

Acreage To Be Disturbed

Existing Impervious Area Within Disturbed

Future Impervious Area Within Disturbed

7. In accordance with the larger common plan of development or sale, enter the total project site acreage, the acreage to be disturbed and the future impervious area (acreage)within the disturbed area. Round to the nearest tenth of an acre.

*note: for gas well drilling, non-high volume hydraulic fractured wells only

7387331596

Name

10. Is this a phased project? Yes No

11. Enter the planned start and end dates of the disturbance activities.

Start Date

End Date

12. Identify the nearest, natural, surface waterbody(ies) to which construction site runoff will discharge.

12a. Type of waterbody identified in Question 12?

Wetland / State Jurisdiction On Site (Answer 12b)

Wetland / State Jurisdiction Off Site

Wetland / Federal Jurisdiction On Site (Answer 12b)

Wetland / Federal Jurisdiction Off Site

Stream / Creek On Site

Stream / Creek Off Site

River On Site

River Off Site

Lake On Site

Lake Off Site

Other Type On Site

Other Type Off Site

12b. How was the wetland identified?

Regulatory Map

Delineated by Consultant

Delineated by Army Corps of Engineers

Other (identify)

13. Has the surface waterbody(ies) in question 12 been identified as a 303(d) segment in Appendix E of GP-0-10-001?

14. Is this project located in one of the Watersheds identified in Appendix C of GP-0-10-001?

Yes No

Yes No

15. Is the project located in one of the watershed areas associated with AA and AA-S classified waters? If no, skip question 16.

Yes No

9155331591

18. Does the site runoff enter a separate storm sewer system (including roadside drains, swales, ditches, culverts, etc)?

19. What is the name of the municipality/entity that owns the separate storm sewer system?

Yes No Unknown

20. Does any runoff from the site enter a sewer classified as a Combined Sewer? Yes No Unknown

16. Does this construction activity disturb land with no existing impervious cover and where the Soil Slope Phase is identified as an E or F on the USDA Soil Survey? If Yes, what is the acreage to be disturbed?

Yes No

21. Has the required Erosion and Sediment Control component of the SWPPP been developed in conformance with the current NYS Standards and Specifications for Erosion and Sediment Control (aka Blue Book) ?

22. Does this construction activity require the development of a SWPPP that includes Water Quality and Quantity Control components (Post-Construction Stormwater Management Practices) (If No, skip questions 23 and 27-35)

23. Have the Water Quality and Quantity Control components of the SWPPP been developed in comformance with the current NYS Stormwater Management Design Manual ?

Yes No

Yes No

Yes No

17. Will the project disturb soils within a State regulated wetland or the protected 100 foot adjacent area?

Yes No

6222331593

SWPPP Preparer

Contact Name (Last, Space, First)

Mailing Address

City

State Zip

Phone

Fax

Email

Signature

Date

First Name

Last Name

MI

SWPPP Preparer Certification

24. The Stormwater Pollution Prevention Plan (SWPPP) was prepared by:

Professional Engineer (P.E.)

Soil and Water Conservation District (SWCD)

Registered Landscape Architect (R.L.A)

Certified Professional in Erosion and Sediment Control (CPESC)

Owner/Operator

Other

I hereby certify that the Stormwater Pollution Prevention Plan (SWPPP) for this project has been prepared in accordance with the terms and conditions of the GP-0-10-001. Furthermore, I understand that certifying false, incorrect or inaccurate information is a violation of this permit and the laws of the State of New York and could subject me to criminal, civil and/or administrative proceedings.

4262331595

26. Select all of the erosion and sediment control practices that will be employed on the project site:

Biotechnical

Brush Matting

Wattling

Other

25. Has a construction sequence schedule for the planned management practices been prepared? Yes No

Brush Matting

Dune Stabilization

Grassed Waterway

Mulching

Protecting Vegetation

Recreation Area Improvement

Seeding

Sodding

Straw/Hay Bale Dike

Streambank Protection

Temporary Swale

Topsoiling

Vegetating Waterways

Vegetative Measures

Check Dams

Construction Road Stabilization

Dust Control

Earth Dike

Level Spreader

Perimeter Dike/Swale

Pipe Slope Drain

Portable Sediment Tank

Rock Dam

Sediment Basin

Sediment Traps

Silt Fence

Stabilized Construction Entrance

Storm Drain Inlet Protection

Straw/Hay Bale Dike

Temporary Access Waterway Crossing

Temporary Stormdrain Diversion

Temporary Swale

Turbidity Curtain

Water bars

Temporary Structural

Debris Basin

Diversion

Grade Stabilization Structure

Land Grading

Lined Waterway (Rock)

Paved Channel (Concrete)

Paved Flume

Retaining Wall

Riprap Slope Protection

Rock Outlet Protection

Streambank Protection

Permanent Structural

5911331597

27. Indicate all Stormwater Management Practice(s) that will be installed/constructed on this site:

Micropool Extended Detention (P-1)

Wet Pond (P-2)

Wet Extended Detention (P-3)

Multiple Pond System (P-4)

Pocket Pond (P-5)

Ponds

Filtering

Surface Sand Filter (F-1)

Underground Sand Filter (F-2)

Perimeter Sand Filter (F-3)

Organic Filter (F-4)

Bioretention (F-5)

Other

Dry Swale (O-1)

Wet Swale (O-2)

Infiltration Trench (I-1)

Infiltration Basin (I-2)

Dry Well (I-3)

Underground Infiltration System

Infiltration

Shallow Wetland (W-1)

Extended Detention Wetland (W-2)

Pond/Wetland System (W-3)

Pocket Wetland (W-4)

28. Describe other stormwater management practices not listed above or explain any deviations from the technical standards.

29. Has a long term Operation and Maintenance Plan for the post-construction stormwater management practice(s) been developed?

If Yes, Identify the entity responsible for the long term Operation and Maintenance

Yes No

Open Channels

Wetlands

Rain Garden

Cistern

Green Roof

Stormwater Planters

Permeable Paving (Modular Block)

Alternative Practice Verified Proprietary Practice Hydrodynamic

Wet Vault

Media Filter

Post-Construction Stormwater Management Practices

Water Quality and Quantity Control

Important: Completion of Questions 27-35 is not required if response to Question 22 is No.

0199331590

IMPORTANT: For questions 31 and 32, impervious area should be calculated considering the project site and all offsite areas that drain to the post-construction stormwater management practice(s). (Total Drainage Area = Project Site + Offsite areas)

32. Pre-Construction Impervious Area - As a percent of the Total Drainage Area enter the percentage of the existing impervious areas before construction begins.

33. Post-Construction Impervious Area - As a percent of the Total Drainage Area, enter the percentage of the future impervious areas that will be created/remain on the site after completion of construction.

WQv Required WQv Provided

. acre-feet

30. Provide the total water quality volume required and the total provided for the site.

. acre-feet

31b. The need to provide for flood control has been waived because:

. CFS CFS.

Post-developmentPre-Development

Total Extreme Flood Control Criteria (Qf) - Peak discharge rate for the 100 year storm

. CFS . CFS

Post-developmentPre-Development

Total Overbank Flood Control Criteria (Qp) - Peak discharge rate for the 10 year storm

Site discharges directly to fourth order stream or larger

31a. The need to provide for channel protection has been waived because:

. acre-feet

CPv Provided acre-feet.

CPv Required

Total Channel Protection Storage Volume (CPv) - Extended detention of post-developed 1 year, 24 hour storm event

31. Provide the following Unified Stormwater Sizing Criteria for the site.

Site discharges directly to fourth order stream or larger

Downstream analysis reveals that flood control is not required

34. Indicate the total number of post-construction stormwater management practices to be installed/constructed.

35. Provide the total number of stormwater discharge points from the site. (include discharges to either surface waters or to separate storm sewer systems)

2994331595

DEC Permits

36. Identify other DEC permits that are required for this project.

40. If this NOI is being submitted for the purpose of continuing coverage under a general permit for stormwater runoff from construction activities, please indicate the former SPDES number assigned.

Owner/Operator Certification I have read or been advised of the permit conditions and believe that I understand them. I also understand that, under the terms of the permit, there may be reporting requirements. I hereby certify that this document and the corresponding documents were prepared under my direction or supervision. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. I further understand that coverage under the general permit will be identified in the acknowledgment that I will receive as a result of submitting this NOI and can be as long as sixty (60) business days as provided for in the general permit. I also understand that, by submitting this NOI, I am acknowledging that the SWPPP has been developed and will be implemented as the first element of construction, and agreeing to comply with all the terms and conditions of the general permit for which this NOI is being submitted.

Owner/Operator Signature

Date

Print First Name

Print Last Name

MI

38. Is this project subject to the requirements of a regulated, traditional land use control MS4?

(If No, skip question 39)

Yes No

39. Has the "MS4 SWPPP Acceptance" form been signed by the principal executive officer or ranking elected official and submitted along with this NOI?

Yes No

Air Pollution Control

Coastal Erosion

Hazardous Waste

Long Island Wells

Mined Land Reclamation

Other SPDES

Solid Waste

None

Other

Navigable Waters Protection / Article 15

Water Quality Certificate

Dam Safety

Water Supply

Freshwater Wetlands/Article 24

Tidal Wetlands

Wild, Scenic and Recreational Rivers

Stream Bed or Bank Protection / Article 15

37. Does this project require a US Army Corps of Engineers Wetland Permit?

If Yes, Indicate Size of Impact.

Yes No

3484331590