Form FEMA Form 086-0-27 FEMA Form 086-0-27 Coastal Structures Form

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
COASTAL STRUCTURES FORM (FORM 5)

OMB Control Number: 1660-0016
Expiration: 4/30/2017

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 3.5 hours per response. The burden estimate includes the time for reviewing
instructions, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form.
You are not required to respond to this collection of information unless it displays a valid OMB control number. Send comments regarding the
accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, Department of
Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472 , Paperwork Reduction Project
(1660-0016). Submission of the form is required to obtain or retain benefits under the National Flood Insurance Program. Please do not send
your completed survey to the above address.
PRIVACY ACT STATEMENT
AUTHORITY: The National Flood Insurance Act of 1968, Public Law 90-448, as amended by the Flood Disaster Protection Act of 1973, Public
Law 93-234.
PRINCIPAL PURPOSE(S): This information is being collected for the purpose of determining an applicant's eligibility to request changes to
National Flood Insurance Program (NFIP) Flood Insurance Rate Maps (FIRM).
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C § 552a(b) of the Privacy Act of 1974,
as amended. This includes using this information as necessary and authorized by the routine uses published in DHS/FEMA/NFIP/LOMA-1
National Flood Insurance Program (NFIP); Letter of Map Amendment (LOMA) February 15, 2006, 71 FR 7990.
DISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested may delay or
prevent FEMA from processing a determination regarding a requested change to a (NFIP) Flood Insurance Rate Maps (FIRM).
Flooding Source:
Note: Fill out one form for each flooding source studied
A. BACKGROUND
1.

Name of Structure:

2.

Location of Structure:

3.

Type of structure (check one):

DRAFT

Levee/Floodwall*

Anchored Bulkhead

Revetment

Breakwater

Pile supported seawall

Other

Gravity Seawall

*Note: If the coastal structure is a levee/floodwall, complete Section E of Form 3 (Riverine Structures Form).
The remainder of this form does not need to be completed.
4.

Material structure is composed of (check all the apply):
Stone

5.

Earthern fill

Concrete

Steel

Sand

Other

The structure is (check one):
New or Proposed

Existing

Modification of existing structure

Replacement structure of the same size and design as what was previously at the site
Describe in detail the existing structure and/or modifications being made to the structure and the purpose of the modifications:

If existing, please include date of construction:
6.

Copies of certified "as-built" plans

are

are not attached. Attach all design analyses that apply.

If "as-built" plans are not available for submittal, please explain why and attach a sketch with general structure dimensions
including: face slope, height, length, depth, and toe elevation referenced to the appropriate datum (e.g. NGVD 1929, NAVD
1988, etc.).
FEMA FORM 086-0-27B (06/17)

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A. BACKGROUND (continued)
7.

Has a Federal agency with responsibility for the design of coastal flood protection structures designed or certified that the structures
have been adequately designed and constructed to provide protection against the 1%-annual-chance event?
Yes
No
If Yes, specify the name of the agency and dates of project completion and certification.

If Yes, then no other sections of this form need to be completed.
8.

An Operation & Maintenance Plan has been provided.(required for all coastal structures)

Yes

No

B. DESIGN CRITERIA
1.

Design Parameters
a.

Were physical parameters representing the 1%-annual-chance event or greater used to design the coastal flood protection
structure?
Yes
No

b.

The number of design water levels that were evaluated

(number) range from the mean low water elevation of

feet to the 1%-annual-chance stillwater surge elevation of
The datum that these elevations are referenced to is

feet. The critical water level is

feet.

e.g., (NGVD)

Attach an explanation specifying which water levels and associated wave heights and periods were analyzed.
c.

Were breaking wave forces used to design the structure?
Yes

2.

No

If No, attach an explanation why they were not used for design.

Settlement
a.

DRAFT

What is the expected settlement rate at the site of the structure?
Please attach a settlement analysis.

3.

Freeboard
a.

Does the structure have 1 foot of freeboard above the height of the 1%-annual-chance wave-height elevation or maximum
wave runup (whichever is greater)?
Yes
No

b.

Does the structure have freeboard of at least 2 feet above the 1% annual chance stillwater surge elevation?
Yes

4.

No

Toe Protection
Specify the type of toe protection:
If no toe protection is provided, provide analysis of scour potential and attach an evaluation of structural stability performed with
potential scour at the toe.

5.

Backfill Protection
Will the structure be overtopped during the 1%-annual-chance event?

Yes

No

If the structure will be overtopped, attach an explanation of what measures are used to prevent the loss of backfill from rundown
over the structure, drainage landward, under or laterally around the ends of the structure, or through seams and drainage
openings in the structure.
6.

Structural Stability - Minimum Water Level
a.

For coastal revetments, was a geotechnical analysis of potential failure in the landward direction by rotational gravity slip
performed for maximum loads associated with minimum seaward water level, no wave action, saturated soil conditions
behind the structure, and maximum toe scour?
Yes
No

b.

For gravity and pile-supported seawalls, were engineering analyses of landward sliding, landward overturning, and of foundation
adequacy using maximum pressures developed in the sliding and overturning calculations performed?
Yes
No

c.

For anchored bulkheads, were engineering analyses performed for shear failure, moment failure, and adequacy of
tiebacks and deadmen to resist loading under low-water conditions?
Yes
No

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B. DESIGN CRITERIA (continued)
7.

Structural Stability - Critical Water Level (Note: All structures must be designed to resist the maximum loads associated with the
critical water level to be credited as providing protection from the 1% annual chance event.)
a.

For coastal revetments, was a geotechnical analysis of potential failure in the seaward direction by rotational gravity slip
or foundation failure due to inadequate bearing strength?

b.

For revetments, were engineering analyses of rock, riprap, or armor blocks' stability under wave action or uplift forces on
the rock, riprap, or armor blocks performed?

Yes

No

Yes

No

c.

Are the rocks graded?
Yes
No

d.

Are soil or geotextile filters being used in the design?
Yes
No

e.

For gravity and pile supported seawalls, were engineering analyses of landward sliding, landward overturning, and
foundation adequacy performed?
Yes

f.

No

For anchored bulkheads, were engineering analyses of shear and moment failure performed using "shock" pressures?
Yes
No
For all analyses marked “No” above for the appropriate type of structure, please attach an explanation why the analyses
were not performed.

8.

Material Adequacy

DRAFT

The design life of the structure given the existing conditions at the structure site is
9.

10.

Ice and Impact Alignment

Yes

No If Yes, attach impact analysis and design details for such forces.

a.

Will the structure be subjected to ice forces?

b.

Will the structure be subjected to impact forces from boats, ships, or large debris?

Structure Plan Alignment
The structure is (check one):

Isolated

years.

Yes

No If Yes, attach impact analysis.

Part of a continuous structure with redundant return walls at frequent intervals.

Please provide a map showing the location of the structure and any natural land features that shelter the structure from wave actions.
C. ADVERSE IMPACT EVALUATION
If the structure is new, proposed, or modified, will the structure impact flooding and erosion for areas adjacent to the structure?
Yes
No
If Yes, attach an explanation.
D. COMMUNITY AND/OR STATE REVIEW
Has the design, maintenance, and impact of the structure been reviewed and approved by the community, and any Federal, State, or local
agencies having jurisdiction over flood control and coastal construction activities in the area the structure impacts?
Yes

No

If Yes, attach a list of agencies who have reviewed and approved the project.
If No, attach an explanation why review and approval by the appropriate community or agency has not been
obtained.

FEMA FORM 086-0-27B (06/17)

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E. CERTIFICATION
As a Professional Engineer, I certify that the above structures will withstand all hydraulic and wave forces associated with the 1% annual
chance flood without significant structural degradation. All documents submitted in support of this request are correct to the best of my
knowledge. I understand that any false statement may be punishable by fine or imprisonment under Title 18 of the United States Code,
Section 1001.
Certifier's Name:

License No.:

Company Name:

Telephone No.:

Signature:

Date:

Exp. Date:
Fax No.:

Seal (optional)

DRAFT

FEMA FORM 086-0-27B (06/17)

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