Fillable Provision C.3 Data Form (City of Campbell)

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Provision C.3 Data Form (City of Campbell)

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BROWSE CITY OF CAMPBELL (CA) FORMS

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Date Form Completed:
Completed by:
SCVURPPP C.3. Data Form Page 1 of 4 September 2019
Santa Clara Valley
Urban Runoff
Pollution Prevention Program
Provision C.3 Data Form
1. Project Information
Project Name: ____________________________________APN # _________________________
Project Address:
Cross Streets:
Applicant/Developer Name:
Project Phase(s): ______of______ Engineer:
Project Type (Check all that apply): New Development Redevelopment
Private Public
Residential Commercial Industrial Mixed Use Institutional
Restaurant Uncovered Parking Retail Gas Outlet Auto Service (SIC code) _________
Other __________________________________________
Project Description: _______________________________________________________________
Project Watershed/Receiving Water (creek, river or bay):________________________________
Which Projects Must Comply with Stormwater Requirements?
All projects that create and/or replace 10,000 sq. ft. or more of impervious surface on the project site must
fill out this worksheet and submit it with the development project application.
All restaurants, auto service facilities, retail gasoline outlets, and uncovered parking lot projects
(stand-alone or part of another development project, including the top uncovered portion of parking
structures) that create and/or replace 5,000 sq. ft. or more of impervious surface on the project site must also
fill out this worksheet.
Interior remodeling projects, routine maintenance or repair projects such as re-roofing and re-paving, and
single family homes that are not part of a larger plan of development are NOT required to complete this
worksheet.
What is an Impervious Surface?
An impervious surface is a surface covering or pavement that prevents the land’s natural ability to absorb and
infiltrate rainfall/stormwater. Impervious surfaces include, but are not limited to rooftops, walkways, paved
patios, driveways, parking lots, storage areas, impervious concrete and asphalt, and any other continuous
watertight pavement or covering. Pervious pavement, underlain with pervious soil or pervious storage
material (e.g., drain rock), that infiltrates rainfall at a rate equal to or greater than surrounding unpaved areas
OR that stores and infiltrates the water quality design volume specified in Provision C.3.d of the Municipal
Regional Stormwater Permit (MRP), is not considered an impervious surface.
For More Information
For more information regarding selection of Best Management Practices for stormwater pollution prevention
or stormwater treatment contact:
(5013-5014, 5541, 7532-7534, 7536-7539)
City of Campbell - Public Works Land Development - (408) 866-2150
Choose from list
SCVURPPP C.3. Data Form Page 2 of 4 September 2019
2. Project Size
a. Total Site Area: ______________acres
Site Totals
Total Existing
(Pre-project)
Area (ft
2
)
Existing Area
Retained
1
(ft
2
)
Existing Area
Replaced
2
(ft
2
)
New Area
Created
2
(ft
2
)
Total Post-
Project Area (ft
2
)
c. Total Impervious Area (IA)
d. Total new and replaced impervious area
e. Total Pervious Area (PA)
3
f. Total Area (IA+PA)
g. Percent Replacement of IA in Redevelopment Projects: (Existing IA Replaced ÷ Existing Total IA) x 100% _______%
3. State Construction General Permit Applicability:
a. Is #2.b. equal to 1 acre or more?
Yes, applicant must obtain coverage under the State Construction General Permit (see
https://www.waterboards.ca.gov/water_issues/programs/stormwater/construction.html)
No, applicant does not need coverage under the State Construction General Permit.
4. MRP Provision C.3 Applicability:
a. Is #2.d. equal to 10,000 sq. ft. or more, or 5,000 sq. ft. or more for restaurants, auto service
facilities, retail gas outlets, and stand-alone uncovered parking?
Yes, C.3. source control, site design and treatment requirements apply
No, C.3. source control and site design requirements may apply – check with local agency
b. For redevelopment projects, is #2.g. equal to 50% or more?
Yes, C.3. requirements (site design and source control, as appropriate, and stormwater
treatment) apply to the entire site
No, C.3. requirements only apply to the impervious area created and/or replaced
c. Does the project create and/or replace 5,000 sf or more of impervious surface parking?
Yes, C.3. requirements may apply to the entire site – check with local agency
No
5. Hydromodification Management (HM) Applicability:
a. Does the project create and/or replace one acre or more of impervious surface AND is the total
post-project impervious area greater than the pre-project (existing) impervious area?
Yes (continue) No – exempt from HM, go to page 3
b. Is the project located in an area of HM applicability (green area) on the HM Applicability
Map? ( www.scvurppp.org/hmp-map)
Yes, the project must implement HM requirements
No, the project is exempt from HM requirements
1
“Retained” means to leave existing IA in place. An IA that goes through maintenance (e.g., pavement resurfacing/slurry
seal/grind), but no change in grade is considered “retained”.
2
The “new” and “replaced” IA are based on the total area of the site and not specific locations on site. For example, impervious
parking created over a pervious area is not “new” IA, if an equal amount of pervious area replaces IA somewhere else on the site.
Constructed IA on a site that does not exceed the total pre-project IA will be considered “replaced” IA. A site will have “new”
IA only if the total post-project IA exceeds the total pre-project IA (total post-project IA – total pre-project IA = New IA).
3
Include bioretention areas, infiltration areas, green roofs, and pervious pavement in PA calculations.
0
0
0
0
SCVURPPP C.3. Data Form Page 3 of 4 September 2019
6. Selection of Specific Stormwater Control Measures:
Site Design Measures
Minimize land disturbed
(e.g., protect trees and soil)
Minimize impervious
surfaces (e.g., reduction in
post-project impervious
surface)
Minimum-impact street or
parking lot design (e.g.,
parking on top of or under
buildings)
Cluster structures/ pavement
Disconnected downspouts
(direct runoff from roofs,
sidewalks, patios to
landscaped areas)
Pervious pavement
Green roof
Other self-treating
4
area
(e.g., landscaped areas)
Self-retaining
4
area
Interceptor trees
3
Rainwater harvesting and
use (e.g., rain barrel, cistern
for designated use)
5
Preserved open space:
_______ ac. or sq. ft. (circle
one)
Protected riparian and
wetland areas/buffers
(Setback from top of bank:
_______ft.)
Other _______________
Source Control Measures
Wash area/racks, drain to
sanitary sewer
5
Covered dumpster area,
drain to sanitary sewer
6
Sanitary sewer connection
or accessible cleanout for
swimming
pool/spa/fountain
6
Beneficial landscaping
(minimize irrigation, runoff,
pesticides and fertilizers;
promotes treatment)
Outdoor material storage
protection
Covers, drains for loading
docks, maintenance bays,
fueling areas
Maintenance (pavement
sweeping, catch basin
cleaning, good
housekeeping)
Storm drain labeling
Other _______________
Treatment Measures
None (all impervious
surface drains to self-
retaining areas)
LID Treatment
Bioretention area
Flow-through planter
Tree Well Filter or Trench
with bioretention soils
Rainwater harvest/use (e.g.,
cistern or rain barrel for
designated use, sized for
C.3.d treatment)
Infiltration trench
Infiltration well/dry well
Subsurface Infiltration
System (e.g. vault or large
diameter conduit over drain
rock)
Other _______________
Non-LID Treatment Methods
Proprietary high flow rate
tree box filter
7
Proprietary high flow media
filter (sand, compost, or
proprietary media)
7
Vegetated filter strip
8
Extended detention basin
8
Vegetated swale
8
Other _______________
Flow Duration Controls for Hydromodification Management (HM)
Extended
Detention basin
Underground tank or
vault
Bioretention with outlet
control
Other
______________
4
See SCVURPPP C3 Handbook for definitions. https://scvurppp.org/2016/06/20/c-3-stormwater-handbook-june-2016/
5
Optional site design measure; does not have to be sized to comply with Provision C.3.d treatment requirements.
6
Subject to sanitary sewer authority requirements.
7
These treatment measures are only allowed if the project qualifies as a “Special Project”.
8
These treatment measures are only allowed as part of a multi-step treatment process (i.e., for pretreatment).
SCVURPPP C.3. Data Form Page 4 of 4 September 2019
7. Stormwater Treatment Measure (STM) Sizing for Projects with Treatment Requirements
Stormwater Treatment Measure (STM)
Hydraulic Sizing Criteria Used
*
*
Key: 1a: Volume – WEF Method
1b: Volume – CASQA BMP Handbook Method
2a: Flow – Factored Flood Flow Method
2b: Flow – CASQA BMP Handbook Method
2c: Flow – Uniform Intensity Method
3: Combination Flow and Volume Design Basis
8. Alternative Certification: Was the treatment system sizing and design reviewed by a qualified third-
party professional that is not a member of the project team or agency staff?
Yes No Name of Third-party Reviewer___________________________
9. Operation & Maintenance Information
A. Property Owner’s Name _________________________________________
B. Responsible Party for Stormwater Treatment/Hydromodification Control O&M:
a. Name: _________________________________________
b. Address: _________________________________________
c. Phone/E-mail: _________________________________________
This section to be completed by Municipal staff.
O&M Responsibility Mechanism
Indicate how responsibility for O&M is assured. Check all that apply:
O&M Agreement
Other mechanism that assigns responsibility (describe below):
________________________________________________________________________________________
This section to be completed by Municipal staff (Note: This is an optional section that agencies should modify per their
internal review and tracking process.)
Reviewed By:
Community Development Department Public Works Department
Planning Division: ______________ Engineering: _______________
Building Division: _______________ Other (Specify):_______________
Return form to: ______________________ Data entry performed by: __________________
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Provision C.3 Data Form (City of Campbell)

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Completed 2 August 2020

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