NPDES STORMWATER PERMIT APPLICATION FORM

This application form is for use by public bodies seeking NPDES stormwater permit coverage for Regulated Public Entities (RPE) pursuant to Title 15A North Carolina Administrative Code 2H .0126. A complete application package includes this form and three copies of the narrative documentation required in Section X of this form. This application form, completed in accordance with Instructions for completing NPDES Small MS4 Stormwater Permit Application (SWU-270) and the accompanying narrative documentation, completed in accordance with Instructions for Preparing the Comprehensive Stormwater Management Program Report (SWU-268) are both required for the application package to be considered a complete application submittal. Incomplete application submittals may be returned to the applicant.

I. APPLICANT STATUS INFORMATION

a. Name of Public Entity Seeking Permit Coverage	Town of Chapel Hill
b. Ownership Status (federal, state, or local)	Local
c. Type of Public Entity (city, town, county, prison, school, etc.)	Town
d. Federal Standard Industrial Classification Code	SIC 91 - 97
e. County(s)	Orange, Durham
f. Jurisdictional Area (square miles)	25.04 mi²
g. Population	Permanent	51,598
	Seasonal (if available)
h. Ten-year Growth Rate	2.3%/year
i. Located on Indian Lands?	Yes X No

II. RPE / MS4 SYSTEM INFORMATION

a. Storm Sewer Service Area (square miles)	25.04 mi²
b. River Basin(s)	Cape Fear
c. Number of Primary Receiving Streams	10: Little Creek, Booker Creek, Bolin Creek, Meeting of the Waters Creek, Cedar Fork Creek, Wilson Creek, Fan Branch Creek, and Battle Branch Creek
d. Estimated percentage of jurisdictional area containing the following four land use activities:
· Residential	53.1%
· Commercial	3.7%
· Industrial	0.3%
· Open Space	18.2%
Total =	75.3%
e. Are there significant water quality issues listed in the attached application report?	X Yes No

III. EXISTING LOCAL WATER QUALITY PROGRAMS

a. Local Nutrient Sensitive Waters Strategy	Yes X No
b. Local Water Supply Watershed Program	X Yes No
c. Delegated Erosion and Sediment Control Program	X Yes No
d. CAMA Land Use Plan	Yes X No

IV. CO-PERMIT APPLICATION STATUS INFORMATION

(Complete this section only if co-permitting)

a. Do you intend to co-permit with a permitted Phase I entity?		Yes X No
b. If so, provide the name and permit number of that entity:
· Name of Phase I MS4
· NPDES Permit Number
c. Do you intend to co-permit with another Phase II entity?	Yes X No
d. If so, provide the name(s) of the entity:
e. Have legal agreements been finalized between the co-permittees?	Yes X No

V. RELIANCE ON ANOTHER ENTITY TO SATISFY ONE OR MORE OF YOUR PERMIT OBLIGATIONS

(If more than one, attach additional sheets)

a. Do you intend that another entity perform one or more of your permit obligations?	X Yes No
b. If yes, identify each entity and the element they will be implementing
· Name of Entity	County of Orange
· Element they will implement	Construction Site Stormwater Runoff Control
· Contact Person	Reynolds Ivins, Erosion Control Supervisor
· Contact Address	Planning and Inspections Department, 306F Revere Road, PO Box 8181, Hillsborough, NC 27278
· Contact Telephone Number	919/245-2586
c. Are legal agreements in place to establish responsibilities?	X Yes No

VI. DELEGATION OF AUTHORITY (OPTIONAL)

The signing official may delegate permit implementation authority to an appropriate staff member. This delegation must name a specific person and position and include documentation of the delegation action through board action.

a. Name of person to which permit authority has been delegated	Not applicable.
b. Title/position of person above
c. Documentation of board action delegating permit authority to this person/position must be provided in the attached application report.

VII. SIGNING OFFICIAL’S STATEMENT

Please see the application instructions to determine who has signatory authority for this permit application. If authority for the NPDES stormwater permit has been appropriately delegated through board action and documented in this permit application, the person/position listed in Section VI above may sign the official statement below.

I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations.
Signature
Name	W. Calvin Horton
Title	Town Manager
Street Address	306 N. Columbia St.
PO Box
City	Chapel Hill
State	NC
Zip	27516
Telephone	919/968-2743 x227
Fax	919/969-2063
E-Mail	[email protected]

VIII. MS4 CONTACT INFORMATION

Provide the following information for the person/position that will be responsible for day to day implementation and oversight of the stormwater program.

a. Name of Contact Person	Fred Royal
b. Title	Stormwater Management Engineer
c. Street Address	306 N. Columbia Street
d. PO Box
e. City	Chapel Hill
f. State	NC
g. Zip	27516
h. Telephone Number	919/968-2833
i. Fax Number	919/932-2954
j. E-Mail Address	[email protected]

IX. PERMITS AND CONSTRUCTION APPROVALS

List permits or construction approvals received or applied for under the following programs. Include contact name if different than the person listed in Item VIII. If further space needed, attach additional sheets.

a. RCRA Hazardous Waste Management Program	None
b. UIC program under SDWA	None
c. NPDES Wastewater Discharge Permit Number	None
d. Prevention of Significant Deterioration (PSD) Program	None
e. Non Attainment Program	None
f. National Emission Standards for Hazardous Pollutants (NESHAPS) preconstruction approval	None
g. Ocean dumping permits under the Marine Protection Research and Sanctuaries Act	N/A
h. Dredge or fill permits under section 404 of CWA	None

X. NARRATIVE APPLICATION SUPPLEMENT: STORMWATER MANAGEMENT PROGRAM REPORT

Attach three copies of a comprehensive report detailing the proposed stormwater management program for the five-year permit term. The report shall be formatted in accordance with the Table of Contents shown below. The required narrative information for each section is provided in the Instructions for Preparing the Comprehensive Stormwater Management Program Report (SWU-268). The report must be assembled in the following order, bound with tabs identifying each section by name, and include a Table of Contents with page numbers for each entry.

TABLE OF CONTENTS

1. Storm Sewer System Information

1.1. Population Served

1.2. Growth Rate

1.3. Jurisdictional and MS4 Service Areas

1.4. MS4 Conveyance System

1.5. Land Use Composition Estimates

1.6. Estimate Methodology

1.7. TMDL Identification

2. RECEIVING STREAMS

3. EXISTING WATER QUALITY PROGRAMS

3.1. Local Programs

3.2. State programs

4. PERMITTING INFORMATION

4.1. Responsible Party Contact List

4.2. Organizational Chart

4.3. Signing Official

4.4. Duly Authorized Representative

5. Co-Permitting Information (if applicable)

5.1. Co-Permittees

5.2. Legal Agreements

5.3. Responsible Parties

6. Reliance on Other Government Entity

6.1. Name of Entity

6.2. Measure Implemented

6.3. Contact Information

6.4. Legal Agreements

7. STORMWATER MANAGEMENT PROGRAM

7.1. Public Education and Outreach on Storm Water Impacts

7.2. Public Involvement and Participation

7.3. Illicit Discharge Detection and Elimination

7.4. Construction Site Stormwater Runoff Control

7.5. Post-Construction Storm Water Management in New Development and Redevelopment

7.6. Pollution Prevention/Good Housekeeping for Municipal Operations