Form Sfn 19145 - Application To Obtain Coverage For Stormwater Discharges - State Of North Dakota, Department Of Health

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FOR DEPT. USE ONLY
APPLICATION (NOTICE OF INTENT) TO OBTAIN
COVERAGE UNDER NDPDES GENERAL PERMIT
Application No.
FOR STORMWATER DISCHARGES ASSOCIATED
WITH CONSTRUCTION ACTIVITY (NDR10-0000)
Date Received
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF WATER QUALITY
SFN 19145 (12/15)
GENERAL INFORMATION
1. Name of Owner of Construction Project
2. Contact First Name
3. Contact Last Name
4. Contact Phone No.
5. Contact E-mail Address
6. Mailing Address
7. City
8. State/Province
9. Zip Code
10. Name of Operator Working at Site
11. Contact First Name
12. Contact Last Name
13. Contact Phone No.
14. Contact E-mail Address
15. Mailing Address
16. City
17. State/Province
18. Zip Code
PROJECT INFORMATION
19. Name of Construction Project
20. Brief Description of Construction Activity
21. Project Start Date
22. Estimated Completion Date
23. Estimated Total Area of Site (acres)
24. Estimated Area of Disturbance (acres)
25. Physical Address
26. City
27. Township
28. Range
29. Section
31. County
30. Quarter Section (ABCD Format)
Project Location
OR
32. Latitude (Decimal Degrees)
33. Longitude (Decimal Degrees)
34. Name of Municipal Storm Sewer System or Description of Receiving Water
Receiving Waters
35. A SWPPP must be prepared and available for review at the time of application. You are not required to submit the SWPPP with the application
unless otherwise notified by the department. The SWPPP must be completed prior to the start of construction (or the applicable construction phase).
Please refer to Part I(D)(2)(c) of the permit.
I certify under penalty of law that I have personally examined and am familiar with the information submitted
RETURN COMPLETED
herein. Based on my inquiry of those individuals immediately responsible for obtaining the information, I
APPLICATION TO:
believe the submitted information is true, accurate, and complete. I am aware that there are significant
penalties for submitting false information including the possibility of fine and imprisonment.
North Dakota Department of Health
36. Printed Name of Owner(s)
37. Title
Division of Water Quality, 4
th
Floor
918 East Divide Avenue
Bismarck, ND 58501-1947
38. Signature of Owner(s)
39. Date
Telephone:
(701) 328-5210
40. Printed Name of Operator(s)
41. Title
Fax:
(701) 328-5200
42. Signature of Operator(s)
43. Date
SFN 19145

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