2. 
4. Application Date*
   Application Date
5. Construction Site Name*
7. Site Address*
9. City*
10. State*
11. Zip Code*
13. Site Owner Name*
15. Address*
17. City*
18. State*
19. Zip Code*
21. Phone Number*
22. Mobile Number*
23. Fax Number*
25. Site Operator Name*
27. Address*
29. City*
30. State*
31. Zip Code*
33. Phone Number*
34. Mobile Number*
35. Fax Number*
37. Expected Construction Start*
    Expected Construction Start
38. Expected Construction Completion*
    Expected Construction Completion
40. Type of Construction*
42. Total Site Acreage*
43. Land Disturbance Acreage*
45. Temporary Sediment Controls*

    Must select at least one option

    1. Filter Fabric (Silt) Fences
    2. Hay Bales
    3. Inlet Protection

    1. Dikes or Swales
    2. Stabilized Entrance and Exits
    3. Vegetative Buffer

    1. Grassy Swales
    2. Rock Filter Dam

    1. Rock Gabions
    2. Other
47. If other, please explain
49. Erosions and Stabilization Practices

    Must select at least one option

    1. Hydromulch Seeding
    2. Sodding

    1. Mulching
    2. Natural Revegetation

    1. Paving

    1. Other
51. If other, please explain
53. Structural Controls

    Only required for drainage areas greater than 10 acres

    1. Temporary Sediment Ponds

    1. Temporary Sediment Traps

    1. Additional Perimeter Controls

    1. Other
55. If other, please explain
57. Permanent Controls

    Only required for construction sites resulting in at least one acre of new improved impervious surface area

    1. On-site Detention (Dry or Wet)
    2. Vegetated Swales

    1. Low Impact Development
    2. Low Velocity Drainage Channels

    1. Regional Detention

    1. Post Construction Peak Flow Equals Pre-Construction Peak Flow
59. For additional information regarding stormwater permitting please visit www.TXMS4.com/jefferson
61. *Fee units are equal to the number of acres rounded up to the next whole number.
    Example: 2.3 acres equals 3 fee units
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63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit Submit and Print

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