DPNR-BP Application — Form III FOR OFFICE USE Page ft of 7 Date received: Date deemed complete: Reviewed by: DEPARTMENT OF PLANNING AND NATURAL RESOURCES DIVISION OF BUILDING PERMITS 45 MARS HILL, Frederiksted, St. Croix, V1 00840 Cyril E. King Airport, Charlotte Amalie, V1 00801 PHONE: (340) 773-1082, FAX: (840) 773-9310/ (840)774-3320, FAX (340) 714 9549 Earth Change Permit Application Form II-Major Development Note to all applicants: A thirty day period shall apply to the review of an earth change plan by DPNR. The 30-day period shail begin with the date of reception indicated above. However, termination of the 30-day period shall not give inferred or automatic approval to the application (12 VI Rules and Regs. $532-12). SECTION A: PROJECT INFORMATION Owner(s) Name as listed on Deed: = Submit Proof of Legal Interest: (Copy of Deed/Lease with Covenants & Restrictions, if applicable or Purchase Agreement/Land Contract) Physical Address: Mailing address of owner: Telephone #: (H) (W) (Cell) Plot No: Estate: Acreage: Parcel Identification Number: = Submit a copy of property tax bill or tax clearance letter (contact Tax Assessor’s Office: 773-6459 (F’Sted), 772-3115 (F’Sted), 776 8505 (STT/STJ) for information.) Zoning: Name and telephone number of project designer, architect, engineer, or draftsman, (Site plan must be stamped by a certified licensed architect, draftsman or engineer. Name & Phone License Number: Name and telephone number of certified earthwork contractor: DPNR-BP Application — Form IE Page 2 of 7 Proposed action(s) — check those that apply: LJ New Construction L] Addition (What is being added & what exists) Other, briefly describe the total scope, including the end result of the proposed developments(s): SECTION B: REQUIRED SUBMITTALS Submit two copies of this application with the following maps for evaluation. Plot to scale the site location on all maps, as available @ Site Plan (see Section D for list of requirements by class; you may consult the VI Environmental Protection Handbook for standards and specifications of conservation practices at www. vidpnr-dep.org/pubs) @ USDA Soil Survey Map (please use the new soil survey map available at www.pr.nrcs.usda.gov/technical/Soil_Survey/) The following maps can be obtained from the Office of the Lieutenant Governor (2 copies each): M@ PNR/PWD/OLG Drawing: Recorded Parcel Map and/or Registered Survey Map (Registered with the Cadastral Section and STAMPED CERTIFIED by the Cadastral Public Surveyor). M@ Official Zoning Map @ FEMA Flood Insurance Rate Map M@ Sediment Reduction Map a Water Resources Map @ Sketch and identify areas to be cleared and proposed Best Management Practices (BMPs) to be installed. In addition, check those that apply: C1 Soil percolation test results (if needed, in TMDL watersheds; you may consult the VI Onsite Sewage Treatment Systems Handbook for standards and specifications of conventional and alternative septic systems at www. vidpnr-dep.org/pubs) Oo USDA Soil Conservation Plan (for agricultural land clearing) O State Historic Preservation Office Phase I Archaeological Resources Survey (for land subdivision) C1 Hydrology report, certified by a licensed professional engineer (for land subdivision); you may use USDA TR55 (www.wec.nrcs.usda.gov/hydro/hydro- tools-models-tr55.html) or comparable method [1] Road and driveway permit from the Department of Public Works (for Public, private road and driveway construction) DPNR-BP Application — Form III Page 3 of 7 SECTION C: REQUIREMENTS FOR SITE PLAN Check those that apply C ) 2) 3) 4) 5) 6) 2) 8) 9) 0 Section 532-23: Major subdivisions (the development of more than one residential building lot) The plan view detail at a scale no smaller than 1”= 100° showing road and lot layout, position of structures (existing and proposed), storm drainage, proposed soil erosion and sediment control measures, proposed water conservation measures. A maximum contour interval of 5 feet, both existing and proposed, reflecting the proposed earth change. (10-foot contours will be permitted in the case of relatively steep topography, i.e. 25% + slopes.) Design detail and profiles on complex measures such as sediment basins, ponds, gray water cisterns, slope protection structures, retaining walls, etc., shall be included. A statement giving the proposed time of establishment for building permits measures. Show all easements on the site and within 50 feet of the property line. Septic system/wastewater treatment: a. setback distances from property lines, water supply, water bodies, and all structures (proposed or existing) b. septic capacity requirements c. septic details with cross section d. disposal site(s) and area of final effluent Letter from the State Historic Preservation Officer - SHPO approving the Phase I Archaeological Resources Survey for the site Provide a hydrology report, certified by a licensed professional engineer. A road and driveway permit shall be obtained from the Department of Public works and a copy submitted with an earth change plan detailing bank stabilization measures, proposed road bank grades and any special slope treatment. Temporary measures to be installed during the construction period shall also be detailed. Section 532-24: Site plans (includes multi-family residential structures, hotels, commercial structures, light and heavy industrial land development) 1) The plan view detail at a scale no smaller than 1”= 100’ showing road and lot layout, position of structures (existing and proposed), storm drainage, proposed soil erosion and sediment control measures, proposed water conservation measures. 2) A maximum contour interval of 5 feet, both existing and proposed, reflecting the 3) 4) proposed earth change. (10-foot contours will be permitted in the case of relatively steep topography, i.e. 25% + slopes.) Design detail and profiles on complex measures such as sediment basins, ponds, gray water cisterns, slope protection structures, retaining walls, etc., shall be included. A statement giving the proposed time of establishment for strategic environmental protection measures. DPNR-BP Application — Form III Page 4 of 7 5) Show all easements on the site and within 50 feet of the property line. 6) Septic system/wastewater treatment: a. setback distances from property lines, water supply, water bodies, and all structures (proposed or existing) b. septic capacity requirements c. septic details with cross section d. disposal site(s) and area of final effluent O Section 532-25: Government construction not covered in preceding classes of land development 1) The plan view detail at a scale no smaller than 1”= 100° showing road and lot layout, position of structures (existing and proposed), storm drainage, proposed soil erosion and sediment control measures, proposed water conservation measures. 2) A maximum contour interval of 5 feet, both existing and proposed, reflecting the proposed earth change. (10-foot contours will be permitted in the case of relatively steep topography, i.e. 25% + slopes.) 3) Design detail and profiles on complex measures such as sediment basins, ponds, gray water cisterns, slope protection structures, retaining walls, etc., shall be included. 4) A statement giving the proposed time of establishment for strategic environmental protection measures. 5) Show all easements on the site and within 50 feet of the property line. 6) Septic system/wastewater treatment: a. setback distances from property lines, water supply, water bodies, and all structures (proposed or existing) b. septic capacity requirements c. septic details with cross section d. disposal site(s) and area of final effluent C Section 532-26: Land clearing 1) A brief earth change plan in written form detailing the proposed method, equipment, and purpose of land clearing. Please check those that apply: [J Crops CL) Livestock C] Both 2) A USDA soil conservation plan is required for land clearing for agricultural purposes. 3) Show all easements on the site and within 50 feet of the property line. DPNR-BP Application — Form Ir Page 5 of 7 @ On PNR/PWD/OLG Drawing, sketch and identify areas to be cleared and proposed Best Management Practices (BMPs) to be installed. O Section 532-27: Public, private road and driveway construction 1) A road and driveway permit shall be obtained from the Department of Public works and a copy submitted with an earth change plan detailing bank stabilization measures, proposed road bank grades and any special slope treatment. Temporary measures to be installed during the construction period shall also be detailed. 2) Show all easements on the site and within 50 feet of the property line SECTION D: Zoning Requirements Table The following shall be completed by the applicant with entries as appropriate for the zoning district in which the activity is taking place. Not all the requirements will necessarily apply to a particular zone. Consult the Zoning Law. PARCEL INFO PLOT NUMBER & ESTATE: ZONING DISTRICT REQUIRED BUILDING SETBACK DISTANCE (FT) SOIL TYPE SLOPE (%) FLOOD ZONE PLOT SIZE (ACRE) PLOT SIZE (SQ. FT.) TOTAL EXCAVATED MATERIAL (CUBIC YARD) LOT DENSITY FIRST FLOOR AREA (SQ. FT.) SECOND FLOOR AREA (SQ. FT.) THIRD FLOOR AREA (SQ. FT.) LIVING AREA (SQ. FT.)/LOT AREA (SQ. FT.) = DENSITY (%) OCCUPANCY OVERALL BUILDING DIMENSIONS (L (ft.) x W (ft.)) NO. OF FLOORS NO. OF DWELLING UNIT(OR FAMILY) No. of Bedroom: No. of Bathroom: No. of Kitchen Maximum ceiling height (ft.) Maximum building height (ft.) DPNR-BP Application — Form III Page 6 of 7 Type of Roof Type of wall Parking: Number & construction type Driveway: Length and construction type CISTERN Roof Area (sq. ft.) CISTERN CISTERN Cistern Capacity (gallon) (REQUIRED) (ACTUAL) Cistern dimension: length (ft.) x width (ft.) x depth (ft.) SEPTIC SYSTEM SEPTIC SYSTEM SEPTIC SYSTEM (REQUIRED) (ACTUAL) Septic Tank Capacity (gallon): Required SepticTank Capacity (gallon): Actual Drainfield Seepage Area (sq. ft.): Required Drainfield Seepage Area (sq. ft.): Actual Number of infiltrator chambers: Required Number of infiltrator chambers: Actual _DISTANCE IN FEET BETWEED Upslope property line Sideslope property line Downslope property line Cistern Potable water line SECTION E: Hydrology Requirements Attach a hydrology report, certified by a licensed professional engineer (PE). Name of PE: License No. The hydrology report must address the following items: * Title 3 VIR&R §138(a)(12)-5(d)(1), base flood elevation must be established for subdivision proposals located within Zone A of the flood zone as delineated on the FIRM. ® Title 29 VIR&R § 294(b) (4)-3 (a) also requires developers to evaluate flood control by: DPNR-BP Application ~ Form HI Page 7 of 7 a Computing the peak discharge of the base flood (100 year - 24 hr rainfall) taking into account projected land use changes in the contributing watershed Determining the specific flooding threat at the site of the proposed development and establishing whether the proposed development is located in a floodway Calculating the water surface elevation based on a hydraulic analysis of the capacity of the water course to convey the base flood Computing the floodway required to convey the base flood without increasing flood heights to an extent which would cause substantial upstream or downstream damage to existing or reasonably anticipated future development Stormwater Construction Permit No: Applicants who intend to obtain initial coverage for a storm water discharge associated with construction activity under the Storm water general permit must submit a complete and accurate NOI application form and appropriate fee at least 21 days prior to the commencement of construction activity. SECTION F: Signature Block Application is hereby made for a permit to authorize the activities described herein. | agree to provide any additional information/data that may be necessary to provide reasonable assurance or evidence to show that the proposed project will comply with the applicable territorial water quality standards or other building permits standards both during construction and after the project is completed. I also agree to provide entry to the project site for the inspectors from building permits in order to make inspections regarding this application. To the best of my knowledge and belief, that such information provided herein is true, complete and accurate. I further certify that I possess the authority to undertake the proposed activities. Signature of Owner(s) Signatures of all individuals listed on deed is required: Date: Revised 6-1! Seller’s name Address Date Dear Sir or Madam: I am the current owner of (property description, size and location). (Buyer’s name) has entered into a land contract with me for the purchase of said property. I hereby grant him/her permission to build on the property, provided that he/she acquire the necessary permits. This letter does not void any term or condition outlined in the land contract. If you have any questions, please contact me at (e-mail or telephone number). Sincerely, (Seller’s name) Notary Subscribed, sworn to and acknowledged before me by the said (seller’s name), this___ day of (month) (year). Notary Public My Commission Expires on: