CLOSE-OUT APPLICATION FORM
This form must be filled out for Town of Summerville Stormwater Construction Projects requiring
a Stormwater Construction Approval upon completion of construction.
A. Name of Project: ___________________________________________________________________
Disturbed Area (to nearest tenth of an acre): _____________________________________________
B. Stormwater Plan Review Approval Date: _______________________________________________
C. NPDES Permit Coverage Number (if applicable): SCR10 ________
D. Owner/Developer Name: ____________________________________________________________
Addres
s: __________________________________________________________________
City: ___________________________________, State: ___________ Zip: _____________
Phone: __________________ Mobile: _________________ Fax: _________________
Emai
l Address: _____________________________________________________________
E. Property Info: Check Box if same as above
Address: __________________________________________________________________
City: ____________________________________ , South Carolina Zip: _____________
Tax Map Number(s): _________________________________________________________
F. Previous Owner Name:
Address: __________________________________________________________________
City: ___________________________________, State: ___________ Zip: _____________
Phone: _________________ Mobile: __________________ Fax: _________________
Emai
l Address: _____________________________________________________________
G. Engineer, Technical Representative or Firm: _____________________________________________
Address: __________________________________________________________________
City: ___________________________________, State: ___________ Zip: _____________
Phone: _________________ Mobile: __________________ Fax: _________________
Emai
l Address: _____________________________________________________________
H. Closeout Information: Date construction completed (MM/DD/YYYY): ______________
a. Is the entire site sufficiently stabilized? YES NO
b. Are all stormwater facilities working properly & ready for long-term
functioning? YES
NO
I. Record/As-built information:
a. Is a PDF and/or digital copy of the site plan (in state plane coordinates,
NAD 83 international feet) showing the as-built stormwater
management system attached to this form? YES NO
Applicant's Certification:
I hereby certify that all construction, development, and/or re-development have been completed in
accordance with the Town requirements and the Town approved project application and all information is
truthful to the best of my knowledge. I realize that I am now responsible for the long-term maintenance
of all stormwater management facilities until a transfer of ownership has been approved by the Town of
Summerville Engineering Department in accordance with the Stormwater Management Ordinance.
______________________________
_____________________________ __________________
Applicant’s Printed Name Applicant’s Signature Date
Town of Summerville, South Carolina Revised April 2015
