REV. 1/2016

ADAMS COUNTY CONSERVATION DISTRICT

670 Old Harrisburg Road, Suite 201 Gettysburg, PA 17325

Phone: 717-334-0636 Fax: 717-337-0730 www.adamscounty.us

APPLICATION FOR AN EROSION & SEDIMENT CONTROL PLAN & NPDES REVIEW

NPDES/E&S District Use Only
$100 per DISTURBED (Acres must be rounded off ) ACRE Fee
$ Paid to the COMMONWEALTH OF
PA CLEAN WATER FUND.
Check # / District Fees
PERMIT Fee (General, Individual or E&S permit)
Paid to ACCD CLEAN WATER FUND.
$ Check #
District SERVICE Fee $
Paid to ACCD. Check #

NOTE: This application MUST BE COMPLETED & SIGNED by the project owner or agent & submitted along with the required plans, narratives, fees, & any other forms or information.

I. PROJECT

Project Name
STATUS
New Revised / REVISION # / DATE / PROJECT ACRES / DISTURBED ACRES
TYPE OF ACTIVITY
Highway Timber Commercial Residential
Government Utility Phased / # OF UNITS

MUNICIPALITY / ESTIMATED START DATE / ESTIMATED FINISH DATE
LOCATION
Latitude (Decimal format) / Longitude (Decimal format )
PROJECT DESCRIPTION

NPDES REQUIRED No If Yes General Permit Individual Permit

EROSION & SEDIMENT CONTROL PERMIT If Yes
Spoil & Borrow if applicable 105 GP/Timber

II. APPLICANT

APPLICANT / PROJECT DESIGNER / OPERATOR
ADDRESS / ADDRESS / ADDRESS
PHONE / PHONE / PHONE
FAX / FAX / FAX
EMAIL / EMAIL / EMAIL
RESPONSIBLE OFFICIAL / RESPONSIBLE OFFICIAL / RESPONSIBLE OFFICIAL

Note: Application will be considered incomplete without original signature and the correct service fee(s).

I certify that the information provided in this application is true and correct to the best of my knowledge. Provision of false information in this application shall subject the applicant to prosecution for providing false information to authorities under the provision of the Pennsylvania Criminal Code, 18P.S.4904.

SIGNATURE of Responsible Official Ð

______Ë Sign here.

III. DISTRICT SERVICE FEES A. through C. payable to the ACCD.

A.  The ACCD Service Fee for plan review and inspection services relative to the E&SPC Program will be based on total, *ACTUAL DISTURBED ACRES.

CHECK ONE DISTURBED ACRES / FORMULA FEE AMOUNT
Less than 0.5 acres
0.5 – < 1 acre
1 – < 5 acres
5 – < 25 acres
> 25 acres / $400 Base Service Fee $400
$800 Base Service Fee $800
*D= Disturbed acres. Do NOT round off for ACCD Fee.
$1,000 Base Service Fee + (“D” x $400) $
$1,500 Base Service Fee + (“D” x $400) $
$3,000 Base Service Fee + (“D” x $400) $

B. E&SPC Plans for Timber Harvest Activities & Chapter 105 Permits $400 Base Service Fee

C. SPOIL & BORROW

1. Sites where the disturbance is less than one (1) acre ………………………... $400 Base Service Fee

2. If the disturbance meets criteria for NPDES permit, the fees will be as per normal procedure for

applying for an NPDES permit.

IV. PERMIT FEES (Check one applicable permit and per disturbed acre fee.)

Permit Fee payable to the ACCD Clean Water Fund.

Per Acre Fee payable to the Commonwealth of PA Clean Water Fund.

NPDES GENERAL Permit Fee……………………………………………………………………$500

$100 Per DISTURBED Rounded off ACRE Fee…………$100/Rounded off Acres

NPDES Individual Permit Fee .…………………………………………………………..... $1,500

$100 Per DISTURBED Rounded off ACRE Fee…………$100/Rounded off Acres

EROSION & SEDIMENT CONTROL GENERAL PERMIT(ESCGP) Fee……………… $500

$100 Per DISTURBED Rounded off ACRE Fee ……… $100/Rounded off Acres

Please note: If a permit is required, the application must have three (3) checks submitted.

V. WATERSHED INFORMATION

1. Stream Name/Designation (WWF; CWF; EV; HQ-CWF; TSF)

2. Distance to Surface Waters of the Commonwealth (in feet)

3. Does the stormwater discharge to impaired waters according to the Chapter 303(d) list?

Stream Name / Zone / Designation
West Conewago Creek Basin, Source to Pleasant Dale Creek HQ-CWF, MF
Birch Run Basin HQ-CWF, MF
Stillhouse RunBasin HQ-CWF, MF
Hosack RunBasin HQ-CWF, MF
Carbaugh RunBasin, Source to first upstream pipeline
crossing (near US Rt. 30) EV, MF
Carbaugh RunBasin, First upstream pipeline
crossing to mouth HQ-CWF, MF
Toms CreekBasin, Source to LR 01053
(SR 3021) Bridge HQ-CWF, MF
Middle CreekBasin, Source to PA 116 Bridge
(near Fairfield) HQ-CWF, MF
Mountain Creek Basin, Source to Toland HQ-CWF, MF
EV=Exceptional Value CWF=Cold Water Fishery MF=Migratory Fishes HQ=High Quality
______
Taken from the Pennsylvania Code, Title 25 Environmental Protection,
DEP Chapter 93, Water Quality Standards.
(February 12, 2011)
For updated information, please contact the Department of Environmental Protection web site at: www.dep.pa.gov

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