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Application For Environmental Permit Chapter 93 "Stormwater Management And Erosion And Sediment Control" Form - Town Of Somers, Westchester County, New York

11/08

TOWN OF SOMERS

WESTCHESTER COUNTY, NEW YORK

APPLICATION FOR ENVIRONMENTAL PERMIT

CHAPTER 93 "STORMWATER MANAGEMENT AND EROSION AND SEDIMENT CONTROL"

Application Processing Affidavit must also be completed. Click here for form.

APPLICATION FEE: $100 for disturbances of five thousand (5,000) square feet and/or for the placement or

removal of 50 cubic yards of soil, plus $500 for each additional acre of disturbance.

OWNER:

___________________

Tel.#: _____________________________

Mailing Address:__________________________________________________________________

APPLICANT:

_________________ _ Tel. #: _____________________

Mailing Address:___________________________________

_______________________

State authority: If other than owner, authorization must be submitted in writing

PREMISES: Sheet:

Block:

Lot:

_______

DESCRIPTION OF WORK AND PURPOSE:

_________________________________________________________________________ __________

SIZE OF ACTIVITY AREA:

feet by

feet

(include all construction activity area)

VOLUME OF EXCAVATED MATERIAL:

(leave blank if not known)

IN CONJUNCTION WITH:

Wetland Permit:

Steep Slopes Permit:

Tree Preservation Permit:

Site Plan:

Subdivision:

PROPOSED STARTING DATE:

PROPOSED COMPLETION DATE:

PLANS PREPARED BY:

DATED:

**Plans and copy of Stormwater Pollution Prevention Plan must be submitted with application.**

LIST OF APPLICABLE COUNTY, STATE, OR FEDERAL PERMITS:_____________________

______________________________________________________________________

____

__________________________________________________

______

LIST OF PROPERTY OWNERS OF RECORD OF LANDS AND CLAIMANTS OF WATER RIGHTS

WITHIN 100 FEET OF SUBJECT PROPERTY

NAME

ADDRESS

BLOCK/LOT

____________________________________________________________________________________

APPLICANT'S SIGNATURE:

DATE:

___

OWNER'S SIGNATURE:___________________________ DATE:____________________

*APPLICATION MUST BE ACCOMPANIED WITH A COMPLETED ENVIRONMENTAL

ASSESSMENT FORM, A VICINITY MAP, A DEVELOPMENT PLAN, EROSION AND SEDIMENT

CONTROL PLAN, AND THE PROPOSED PHASING OF DEVELOPMENT OF THE SITE.

………………………………….............................Office Use Only………………………………..........................

Administrative Permit:_______________

Planning Board Permit:________________

C:\Documents and Settings\tsavva.SOMERSNY\Local Settings\Temporary Internet Files\OLK124F\Somers_PE_Erosion Sediment Control 2006.DOC

Application For Environmental Permit Chapter 93 "Stormwater Management And Erosion And Sediment Control" Form - Town Of Somers, Westchester County, New York

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