HomeMy WebLinkAboutWPO201800061 Registration Statement 2018-09-12 Registration Statement
General VPDES Permit for Discharges of Stormwater from Construction Activities (VAR10)
(Please Type or Print All Information)
1. Construction Activity Operator: (General permit coverage will be issued to this operator. The Certification in Item #12 must be
signed by the appropriate person associated with this operator)
Name: Scheumann Residence
Contact: Jon or Cathy Scheumann
Mailing Address: 508 Ashley Way
City- Peachtree City State: GA Zip: 30269 Phone:
Email address (if available) k n 5 cl,le v rnann q(n,0,;A M
Indicate if DEQ may transmit general permit correspondence electronically: Yes® No❑
2. Existing General Permit Registration Number(for renewals only):
3. Name and Location of the Construction Activity:
Name: Scheumann Residence
Address(if available):
City: North Garden State: VA Zip: 22959
County(if not located within a City).
Latitude(decimal degrees): 37.96397 Longitude(decimal degrees)778.67519
Name and Location of all Off-site Support Activities to be covered under the general permit:
Name:
Address(if available):
City- State Zip.
County(if not located within a City).
Latitude(decimal degrees): Longitude(decimal degrees):
4. Status of the Construction Activity(check only one): Federal❑ State❑ Public❑ Private IN
5. Nature of the Construction Activity(e.g.,commercial,industrial,residential,agricultural, oil and gas,etc.):
Residential
6. Name of the Receiving Water(s)and Hydrologic Unit Code(HUC):
Name: North Fork Hardware River Name:
HUC: 020802031201 HUC:
7. If the discharge is through a Municipal Separate Storm Sewer System(MS4),the name of the MS4 operator:
8. Estimated Project Start and Completion Date:
Start Date(mm/dd/yyyy): 10/01/18 Completion Date(mm/dd/yyyy): 10/01/19
9. Total Land Area of Development(to the nearest one-hundredth acre): 2.50
Estimated Area to be Disturbed(to the nearest one-hundredth acre): 2.50
10. Is the area to be disturbed part of a larger common plan of development or sale? Yes❑ No
11. A stormwater pollution prevention plan (SWPPP) must be prepared in accordance with the requirements of the General
VPDES Permit for Discharges of Stormwater from Construction Activities prior to submitting this Registration Statement
By signing this Registration Statement the operator is certifying that the SWPPP has been prepared.
12. Certification: "I certify under penalty of law that I have read and understand this Registration Statement and that this document
and all attachments were prepared in accordance with a system designed to assure that qualified personnel properly gathered and
evaluated 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
fine and imprison nt for knowin violations."
Printed Name: LATHY NEi..)MaNN Title: Du}/7Pf'
Signature: i.4.rQ41 ^&,� �j Date: /r�-SQPI - C)4-5
(Please sign in INK.GThis Certification must be signed by the appropriate person associated with the operator identified in
Item#1.)
07/2014
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