ENG Form 4345 Application for Department of Army Permit

APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT

OMB APPROVAL NO. 0710-0003

(33 CFR 325)
Public reporting burden for this collection of information is estimated to average 11 hours per response, including 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, Executive Services and Communications Directorate, Information Management Division and to the Office of Management and Budget,
Paperwork Reduction Project (0710-0003). Respondents should be aware that notwithstanding any 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 currently 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: Rivers and Harbors Act, Section 10, 33 USC 403; Clean Water Act, Section 404, 33 USC 1344; Marine Protection, Research, and Sanctuaries
Act, Section 103, 33 USC 1413; Regulatory Programs of the Corps of Engineers; Final Rule 33 CFR 320-332. 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, and the public and may be made available as part of a public notice as required by Federal law. 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 COMPLETE

(ITEMS BELOW TO BE FILLED BY APPLICANT)
8. AUTHORIZED AGENT'S NAME AND TITLE (an agent is not required)

5. APPLICANT'S NAME:
First ­

Middle ­

First ­

Last –

Company –

Company –

E-mail Address –

E-mail Address –

6. APPLICANT'S ADDRESS.
Address ­

9. AGENT'S ADDRESS
Address ­

City –

State –

Zip –

Country –

City –

7. APPLICANT'S PHONE NOs. W/AREA CODE.
a. Residence

b. Business

Middle ­

State –

Last –

Zip –

Country –

10. AGENT'S PHONE NOs. W/AREA CODE
c. Fax

a. Residence

b. Business

c. Fax

STATEMENT OF AUTHORIZATION
11. 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 (if applicable)

(if applicable)

Address
15. LOCATION OF PROJECT
Latitude: °N
Longitude:

City ­

°W

16. OTHER LOCATION DESCRIPTIONS, IF KNOWN (see instructions)
State Tax Parcel ID
Municipality
Section –
Township –

State –

Zip -

Range –

17. DIRECTIONS TO THE SITE

ENG FORM 4345,

EDITION OF OCT 2004 IS OBSOLETE

(Proponent: CECW-OR)

18. Nature of Activity

19. Project Purpose

(Description of project, include all features)

(Describe the reason or purpose of the project, see instructions)

USE BLOCKS 20-23 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:
Type
Amount in Cubic Yards

Type
Amount in Cubic Yards

22. Surface Area in Acres of Wetlands or Other Waters Filled

Type
Amount in Cubic Yards

(see instructions)

Acres
Or
Liner Feet
23. Description of Avoidance, Minimization, and Compensation

24. Is Any Portion of the Work Already Complete? Yes

No

(see instructions)

IF YES, DESCRIBE THE COMPLETED WORK

25. Addresses of Adjoining Property Owners, Lessees, Etc., Whose Property Adjoins the Waterbody (If more than can be entered here, please attach a supplemental list).
Address –
City –

State –

Zip –

26. 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

27. 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.

(Reverse of ENG FORM 4345