Fillable Land Disturbance Permit Application and Checklist (Town of Acton, Massachusetts)

Fill Online, Printable, Fillable, Blank Land Disturbance Permit Application and Checklist (Town of Acton, Massachusetts) Form

Use Fill to complete blank online TOWN OF ACTON, MASSACHUSETTS (MA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Land Disturbance Permit Application and Checklist (Town of Acton, Massachusetts)

On average this form takes 22 minutes to complete

The Land Disturbance Permit Application and Checklist (Town of Acton, Massachusetts) form is 5 pages long and contains:

  • 0 signatures
  • 25 check-boxes
  • 76 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Town of Acton, Massachusetts

BROWSE TOWN OF ACTON, MASSACHUSETTS (MA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Land Disturbance Form: LD-2019-03
TOWN OF ACTON
472 MAIN STREET
ACTON, MASSACHUSETTS, 01720
TELEPHONE (978) 929-6630
FAX (978) 929-6340
ENGINEERING@ACTON-MA.GOV
Land Disturbance Permit Application and Checklist
______________________________________________________________________________________
An applicant must be familiar with the Town of Acton Stormwater Bylaw (Chapter X) and Rules
and Regulations prior to submitting the application.
Authority
These rules are adopted by the Board of Selectmen as authorized under the authority granted by
the Home Rule Amendment, Article LXXXIX (89) of the Constitution of the Commonwealth of
Massachusetts, the Home Rules statues, and in accordance with the regulations of the federal
Clean Water Act found at 40 CFR 122.34, the Phase II rule from the Environmental Protection
Agency found in the December 8, 1999 Federal Register, and the National Pollutant Discharge
Elimination System General Permit for Stormwater Discharges from Small Municipal Separate
Storm Sewer Systems issued by EPA Region 1 on April 18, 2003.
Purpose
The purpose of this permit is to establish Stormwater management requirements and controls that
protect the public health, safety and welfare for the Town of Acton.
Applicability
This permit shall apply to all Land Disturbance and Development within the jurisdiction of the Town
of Acton. Except in accordance with a Land Disturbance Permit issued pursuant to the Chapter X
Stormwater Management and Erosion & Sediment Control bylaw, no Person shall perform any
Land Disturbance that results in one or more of the Regulated Activities defined in Section 6.1 of
the bylaw that is not an Exempt Activity listed in Section 7.1
Thresholds
A Land Disturbance Permit is required if any of the following criteria apply:
1. Disturbance OR development of 1 acre (43,560 square feet) of land.
2. Disturbance OR development of 5,000 square feet within areas of a 10% slope or greater
3. Disturbance OR creation of 5,000 square feet or more of impervious area
4. Construction of a new drainage system OR alteration of an existing system
It is the responsibility of the owner to notify the Engineering
Department seven (7) days prior to the commencement of any
construction or clearing.
Land Disturbance Form: LD-2019-03
Permit Categories (check applicable category)
Exempt Activities (to be submitted with Building or Demolition Permits)
o Single-Family Home activities that are…(all conditions must apply):
o Below Chapter X Thresholds
o Located within Groundwater Protection Zones 3 or 4
o Is not part of a Common Plan of Development
o Activity below permit thresholds or otherwise exempt: ______________
o Activities with approved stormwater management (check all that apply)
o Order of Conditions (MassDEP File #:_________________________)
o Site Plan Special Permit (Site Plan Permit #:___________________)
o Definitive Subdivision (Subdivision Decision #:_________________)
o Comprehensive Permit (Permit #:__________________________)
Type 1 Permit – Erosion Control ONLY: required for disturbances greater than or
equal to the Chapter X Thresholds without a permanent alteration of drainage
characteristics of the site (check all that apply)
o Replacement and/or construction of a non-stormwater utility
o Activity which does not increase the pre-development impervious area
o Other Activity: ______________________________
Type 2 Permit – Stormwater Management & Erosion Control
o Residential
o ANR Subdivision or other Common Plan of Development
o Other New Construction: ________________________
o Redevelopment
o Commercial
o New Construction
o Redevelopment
o Other Activity: ________________________
Land Disturbance Permit Fee Schedule
Exempt Activities
$0
Erosion Control Only
$250
Stormwater Management and Erosion Control
$1500
GPS Survey Support
$100 per benchmark
Number of Benchmarks Requested & Fee:
____ benchmarks
$_____ fee
Land Disturbance Form: LD-2019-03
Land Disturbance Permit Application
Applicant Information
Applicant
Name:
Date:
First
M.I.
Applicant
Address:
Company/Individual Name Street Address
Apartment/Unit #
City
State
ZIP Code
Phone:
Email
Contractor Responsible for Construction Site Erosion & Sedimentation Control
Company:
Date:
Contact
Name:
First
M.I.
Address:
Street Address
Suite / Floor #
City
State
ZIP Code
Phone:
Email
Project Scope & Description
Project
Location:
Street Address Apartment/Unit #
Map/Parcel
Record
Owner:
Last Name (or Trust/Company)
First
M.I.
Signature
Project/Land Disturbance Description:
(See Section 3.4 of Rules)
(Use additional sheets if necessary)
Project
Plans:
Title
Date:
Land Disturbance Form: LD-2019-03
Land Disturbance Thresholds & Certification
(All disturbances are presumed to be regulated by Chapter X unless completed)
Land Disturbance Threshold Check
(to be completed by a Qualified Consultant)
Area (sq.ft or acres)
Total area of land disturbance
Area of disturbance on a 10% slope
Created:
Impervious area created or altered
(includes roofs, pools, pavement, etc)
Altered Only:
Check if applicable:
Project creates OR alters a stormwater system or conveyance
Drainage area serviced:__________ (sq.ft/ac) Impervious Area Served:________ sq.ft
Project is subject to the National Pollution Discharge Elimination System (NPDES) General
Permit for Storm Water Discharges from Construction Activities
NOI #_______________________ (Include copy of NOI with application)
EPA Tracking #______________ (Include copy of receipt of EPA Authorization Letter)
Qualified Consultant Information
Company:
Date:
Name:
First
M.I.
License Number
Address:
Street Address
Suite / Floor #
City
State
ZIP Code
Phone:
Email
Certification (stamp):
Please find the required documentation to be provided when turning in your application.
See sections (i.e. “3.4”) of Rules & Regulations for detailed descriptions:
Land Disturbance Form: LD-2019-03
Exempt Activities
Must provide a completed land disturbance application and the following:
Activity Below Permit Thresholds
o Site Plan showing land disturbance
Activity With Approved Stormwater Management
o Copy of Order of Conditions and/or Approved Decision
o All Type 2 Permit requirements required by the Approved Decision
Other Exempt Activities
o Any applicable materials within Section 3.1
Type 1 Permit – Erosion Control Only:
o Completed Land Disturbance Application
o Erosion Control Bond: $10,000 per acre disturbed ($10,000 minimum) [Not Required
for Public Utilities]
o Erosion Control & Sedimentation Plan (3.4.10)
o NPDES Construction General Permit (3.4.12) [if applicable]
Type 2 Permit – Erosion Control & Stormwater Management:
o All Type 1 Permit Requirements
o Certified Abutters List (3.4.1) & Proof of mailing (i.e. green cards)
o Stormwater Management Report which includes:
Land Disturbance Description (3.4.2)
Other Permits & Variances (3.4.3)
Recorded Plans & Deeds (3.4.4)
Calculations: Earth Removal, Drainage & Water Balance Calculations (3.4.5 to 3.4.8)
Stormwater Checklist (3.4.9)
Cost Estimate for Erosion Control & Stormwater System Performance Bond (1.6)
Operation & Maintenance Plan (3.4.11)
o Site Plans (3.4.13):
Existing & Proposed Site Features (3.4.13.1 through 3.4.13.9)
Erosion Control & Sedimentation Plan (3.4.10)
o Post-Construction Requirements: To be submitted upon project completion
Inspection Logs [kept by applicant during construction] (3.5.2)
As-Built Plan (5.8) & Certification (5.8.3)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Land Disturbance Permit Application and Checklist (Town of Acton, Massachusetts)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 11 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document