APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT
The Public burden for this
collection of information is estimated to average 10 hours per response,
although the majority of applications should require 5 hours or less.
This includes the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding this burden
estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to Department of Defense, Washington
Headquarters Service Directorate of Information Operations and Reports, 1215
Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302; and to the
Office of Management and Budget, Paperwork Reduction Project (0710-0003),
Washington, DC 20503. Respondents should be aware that notwithstanding
and other provision of law, no person shall be subject to any penalty for
failing to comply with a collection of information if it does not display a
current valid OMB control number. Please DO NOT RETURN your form to
either of those addresses. Completed applications must be submitted to the
District Engineer having jurisdiction over the location
of the proposed activity.
PRIVACY ACT STATEMENT
Authorities: River and Harbors
Act, Section 10, 33 USC 403; Clean Water Act Section 404, 33 USC 1344; Marine
Protection, research and Sanctuaries Act, 33 USC 1413, section 102.
Principal Purpose: Information provided on this form will be used in
evaluating the application for a permit. Routine Uses: This information
may be shared with the Department of Justice and other federal, state, and
local government agencies. Submission of requested information is
voluntary, however, if information is not provided the permit application
cannot be evaluated nor can a permit be issued.
One set of original drawings or good
reproducible copies which show the location and character of the proposed
activity must be attached to this application (see sample drawings and
instructions) and be submitted to the District Engineer having jurisdiction
over the location of the proposed activity. An application that is not
completed in full will be returned.
(ITEMS 1 THRU 4 TO BE FILLED BY THE CORPS)
1. Application No. | 2. Field Office Code | 3. Date Received | 4. Date Application Completed | | | | | |
(ITEMS BELOW TO BE FILLED BY APPLICANT)
5. Applicant's Name | 8. Authorized Agent's Name and Title | |
6. Applicant's Address | 9. Agent's Address | |
7. Applicant's Phone No. w/Area Code | 10. Agent's Phone No. w/Area Code a. Residence | a. Residence b. Business | b. Business
STATEMENT OF
AUTHORIZATION
I hereby authorize _________________________________________________________ to act in my behalf as my agent in the processing of this application and to furnish, upon request, supplemental information in support of this permit application.
_____________________________ ____________ Applicant's Signature Date
NAME, LOCATION,
AND DESCRIPTION OF PROJECT OR ACTIVITY
12. Project Name or Title (see instructions)
13. Name of Waterbody, if Known | 14. Project Street Address | | |-------------------------------------------|15. Location of Project | | ________________ _______ | County State |
16. Other Location Descriptions, if Known (see instructions.)
17. Directions to the Site
18. Nature of Activity (Description of project, include all features)
19. Project Purpose (Describe the reason or purpose of the project, see instructions)
USE BLOCKS 20-22
IF DREDGED AND/OR FILL MATERIAL IS TO BE DISCHARGED
20. Reason(s) for Discharge
21. Type(s) of Material Being Discharged and the Amount of Each Type in Cubic Yards
22. Surface Area in Acres of Wetlands or Other Waters Filled (see instructions)
23. Is Any Portion of the Work Already Complete? Yes _____ No _____ IF YES, DESCRIBE THE COMPLETED WORK
24. Addresses of Adjoining Property Owners, Lessees, Etc., Whose Property Adjoins the Waterbody (If more than can be entered here, please attach a supplemental list).
25. List of Other Certifications or Approvals/Denials Received from other Federal, State, or Local Agencies for Work Described in This Application.
AGENCY TYPE APPROVAL* IDENTIFICATION NUMBER DATE APPLIED DATE APPROVED DATE DENIED
* Would include but is not restricted to zoning, building, and flood plain permits
26. Application is hereby made for a permit or permits to authorize the work described in this application. I certify that the information in this application is complete and accurate. I further certify that I possess the authority to undertake the work described herein or am acting as the duly authorized agent of the applicant.
________________________ ______ ____________________ ______ Signature of Applicant Date Signature of Agent DATE
The application must be signed by the person who desires to undertake the proposed activity (applicant) or it may be signed by a duly authorized agent if the statement in block 11 has been filled out and signed.
18 U.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals, or covers up any trick, scheme, or disguises a material fact or makes any false, fictitious or fraudulent statements or representations or makes or uses any false writing or document knowing same to contain any false, fictitious or fraudulent statements or entry, shall be fined not more than $10,000 or imprisoned not more than five years or both.
Drawings
General Information
Three types of drawings - Vicinity, Plan, and Elevation - are required to accurately depict activities.
Submit one original, or good quality copy, of all drawings on 8½ X 11 inch white paper (tracing cloth or film may be used). Submit the fewest number of sheets necessary to adequately show the proposed activity. Drawings should be prepared in accordance with the general format of the samples, using block style lettering . Each page should have a title block. See check list below. Drawings do not have to be prepared by an engineer, but professional assistance may become necessary if the project is large or complex.
Leave a 1-inch margin at the top edge of each sheet for purposes of reproduction and binding.
In the title block of each sheet of drawings identify the proposed activity and include the name of the body of water; river mile (if applicable); name of county and state; name of applicant; number of the sheet and total number of sheets in set; and date the drawing was prepared.
Since drawings must be reproduced, use
heavy dark lines. Color shading cannot be used; however, dot shading, hatching,
or similar graphic symbols may be used to clarify line drawings.
Vicinity Map
The vicinity map you provide will be printed in any public notice that is issued and used by the Corps of Engineers and other reviewing agencies to locate the site of the proposed activity. You may use an existing road map or US Geological Survey topographic (scale 1:24,000) as the vicinity map. Please include sufficient details to simplify locating the site from both the waterbody and from land. Identify the source of the map or chart from which the vicinity map was taken and, if not already shown, add the following:
· location of activity site (draw an arrow showing the exact location of the site on the map).
· latitude, longitude, river mile, if known, and/or other information that coincides with Block 6 on the application form.
· name of waterbody and the name of the larger creek, river, by, etc., that the waterbody is immediately tributary to.
· names, descriptions and location of landmarks.
· name of all applicable political (county, parish, borough, town, city, etc.) jurisdictions
· name of and distance to nearest town, community, or other identifying locations
· names or numbers of all roads in the vicinity of the site.
· north arrow.
· scale.
Plan View
The plan view shows the proposed activity as if you were looking straight down on it from above. your plan view should clearly show the following:
· Name of waterbody (river, creek, lake, wetland, etc.) and river mile (if known) at location of activity.
· Existing shorelines.
· Mean high and mean low water lines and maximum (spring) high tide line in tidal areas.
· Ordinary high water line and ordinary low water line if the proposed activity is located on a non-tidal waterbody.
· Average water depths around the activity.
· Dimensions of the activity and distance it extends from the high water line into the water.
· Distances to nearby Federal projects, if applicable.
· Distance between proposed activity and navigation channel, where applicable.
· Location of structures, if any, in navigable waters immediately adjacent to the proposed activity.
· Location of any wetlands (marshes, swamps, tidal flats, etc.)
· North arrow.
· Scale.
· If dredged material is involved, you must describe the type of material, number of cubic yards, method of handling, and the location of fill and spoil disposal area. The drawing should show proposed retention levees, weirs, and/or other means for retaining hydraulically placed materials.
· Mark the drawing to indicate previously
completed portions of the activity.
Elevation and/or Cross Section View
The elevation and/or cross section view is a scale drawing that shows the side, front, or rear of the proposed activity. If a section view is shown, it represents the proposed structure as it would appear if cut internally for display. Your elevation should clearly show the following:
· Water elevations as shown in the plan view.
· Water depth at waterward face of proposed activity or, if dredging is proposed, dredging and estimated disposal grades.
· Dimensions from mean high water line (in tidal waters) of proposed fill or float, or high tide line for pile supported platform. Describe any structures to be built on the platform.
· Cross section of excavation or fill, including approximate side slopes.
· Graphic or numerical scale.
· Principal dimensions of the activity.
Notes on Drawings*
· Names of adjacent property owners who may be affected. Complete names and addresses should be shown in Block 5 on ENG Form 4345.
· Legal property description: Number, name of subdivision, block, and lot number. Section, Township, and Range (if applicable) from plot, deed, or tax assessment.
· Photographs of the site of the proposed activity are not required; however, pictures are helpful and may be submitted as part of any application.
· While illustrations need not be professional (many small, private project illustrations are prepared by hand), they should be clear, accurate, and contain all necessary information.
* Drawings should be as clear and simple as
possible (i.e., not too "busy").