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Application for General Permit to <br />Discharge Stormwater Associated with O Change of Information <br />Construction Activity <br />ntunn. not (Notice of Intent) <br />Permlta503------- - <br />E Ct0'6t0`6 Y <br />(Please print in Ink or type) Please Read Not Instructions Before Riling Out This Form <br />1. Contact Person II. Owner/Representative of Site <br />le N. Kussman (425)486-8300 1 Michael R <br />PO Box 1705 1 510 Ra <br />Bothell WA 98041-1705 1 Seattle WA 98144 ■ <br />III. Site Location/Address IV. Billing Address <br />Site Name <br />Name Phone No. <br />Camelot Apartments <br />Michael R. astro 206)323-5393 <br />Street Address (or Location Description) 1515-112 th S t . S W <br />Company Name <br />Ever reen Wa SR99 & 112th St. SW) <br />G & M Investments <br />Ciry(anearestcity) Zip+� <br />Iry ress <br />Everett 98201 <br />510 Rainier Avenue S. <br />d <br />County <br />City State Zlp+4 <br />Snohomish <br />Seattle WA 98144 <br />PL ovide legal description If no address fors (attach separate sheet if necessary) <br />wwd <br />V. Recelvina Water Information khedc all that apply) <br />Does your construction site discharge stormwater to. <br />1. 0 Storm drain system - Owner of storm drain system (name) <br />3 Indirectly or directly to surface waters (e.g., river, lake, creek estuary, ocean, wetland) <br />3. U Directly to ground waters of Washington state. ❑ Dry Well ❑ Drainfkkl ❑ Other <br />8. Name(s) of receiving water(s) Wetland tributary to Lake Stickney and Swamp Creek <br />Initial discharge Is to an unnamed receiving water? ® Yes ❑ No <br />VI. Construction <br />1. Total area to be disturbed 10.3 Acres <br />2. Projected construction startup Sept / 1999 ;projectedcompletiondate 2000 <br />month year month <br />VII. Stormwater Pollution Prevention Plan <br />Has a stormwater pollution prevention plan been developed? ❑ Yes ® No <br />if NO, will a plan be developed prior to the start of construction? ® Yes 0 No <br />Ecology must be notified that a SWPPP will be developed prior to the start of construction by checking the appropriate <br />above or by sending a follow-up letter to Ecology. <br />