6082 US Army Corps of Engineers Nationwide Permit Pre-Contruc

U.S. ARMY CORPS OF ENGINEERS NATIONWIDE PERMIT PRE-CONSTRUCTION NOTIFICATION 33 CFR 330. The proponent agency is CECW-CO-R.			OMB No. 0710-0003 Expires: XX XXX XX
The public reporting burden for this collection of information, 0710-0003, 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 the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at [email protected]. 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 RESPONSE TO THE ABOVE ADDRESS. Responses should be sent to U.S. Army Corps of Engineers, 441 G. Street N.W., Washington, D.C. 20314 Attn: CECW-CO-R. 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/or 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. PRIVACY ACT STATEMENT Authorities: Rivers and Harbors Act, Section 10, 33 USC 403; Clean Water Act, Section 404, 33 USC 1344; 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 nationwide permit pre-construction notification. 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 the agency coordination process. Submission of requested information is voluntary, however, if information is not provided the permit application cannot be evaluated nor can a permit be issued.
(ITEMS 1 THRU 4 TO BE FILLED BY THE CORPS)
1. APPLICATION NUMBER	2. FIELD OFFICE CODE	3. DATE RECEIVED	4. DATE PCN COMPLETE
(ITEMS BELOW TO BE FILLED BY APPLICANT)
5. APPLICANT’S NAME First – Last – Company – Company Title- E-mail address –		8. AUTHORIZED AGENT’S NAME and TITLE (agent is not required) First – Last – Company – E-mail address –
6. APPLICANT’S ADDRESS: Address – City – State – Zip – Country –		9. AGENT’S ADDRESS: Address – City – State – Zip – Country –
7. APPLICANT’S PHONE NOs. with AREA CODE a. Residence – b. Business c. Fax d. Mobile		10. AGENT’S PHONE NOs. with AREA CODE a. Residence – b. Business c. Fax d. Mobile
STATEMENT OF AUTHORIZATION
11. I hereby authorize, _____________________________ to act in my behalf as my agent in the processing of this nationwide permit pre-construction notification and to furnish, upon request, supplemental information in support of this nationwide permit pre-construction notification. ________________________________________________ ________________ SIGNATURE OF APPLICANT DATE
NAME, LOCATION, AND DESCRIPTION OF PROJECT OR ACTIVITY
12. PROJECT NAME or TITLE (see instructions)
13. NAME OF WATERBODY, IF KNOWN (if applicable)		14. PROPOSED ACTIVITY STREET ADDRESS (if applicable) Address: City: State: Zip:
15. LOCATION OF PROPOSED ACTIVITY (see instructions) Latitude: °N Longitude: °W
16. OTHER LOCATION DESCRIPTIONS, IF KNOWN (see instructions) State Tax Parcel ID Municipality Section: Township: Range:

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17. DIRECTIONS TO THE SITE.

18. IDENTIFY THE SPECIFIC NATIONWIDE PERMIT(S) YOU PROPOSE TO USE:

19. DESCRIPTION OF PROPOSED NATIONWIDE PERMIT ACTIVITY (see instructions)

20. DESCRIPTION OF PROPOSED MITIGATION MEASURES (see instructions)

21. PURPOSE OF NATIONWIDE PERMIT ACTIVITY (Describe the reason or purpose of the project, see instructions)

22. Quantity of Wetlands, Streams, or Other Types of Waters Directly Affected by Proposed Nationwide Permit Activity (see instructions)

Acres: Linear feet: Cubic yards dredged or discharged:

Each PCN must include a delineation of wetlands, other special aquatic sites, and other waters, such as lakes and ponds, and perennial, intermittent, and ephemeral streams, on the project site.

23. List any other NWP(s), regional general permit(s), or individual permit(s) used or intended to be used to authorize any part of the proposed project or any related activity (see instructions)

24. If the proposed activity will result in the loss of greater than 1/10-acre of wetlands and requires pre-construction notification, explain how the compensatory mitigation requirement in paragraph (c) of general condition 23 will be satisfied, or explain why the adverse environmental effects are no more than minimal and why compensatory mitigation should not be required for the proposed activity.

25. Is Any Portion of the Nationwide Permit Activity Already Complete? □ Yes □ No If Yes, describe the completed work:

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26. List the name(s) of any species listed as endangered or threatened under the Endangered Species Act that might be affected by the proposed NWP activity or utilize the designated critical habitat that may might be affected by the proposed NWP activity. (see instructions)

27. List any historic properties that have the potential to be affected by the proposed NWP activity or include a vicinity map indicating the location of the historic property. (see instructions)

28. For a proposed NWP activity that will occur in a component of the National Wild and Scenic River System, or in a river officially designated by Congress as a “study river” for possible inclusion in the system while the river is in an official study status, identify the Wild and Scenic River or the “study river”:

29. If the proposed NWP activity also requires permission from the Corps pursuant to 33 U.S.C. 408 because it will alter or temporarily or permanently occupy or use a U.S. Army Corps of Engineers federally authorized civil works project, have you submitted a written request for section 408 permission from the Corps district having jurisdiction over that project? □ Yes □ No

If “yes”, please provide the date your request was submitted to the Corps District:

30. If the terms of the NWP(s) you want to use require additional information to be included in the PCN, please include that information in this space or provide it on an additional sheet of paper marked Block 30. (see instructions)

31. Pre-construction notification is hereby made for one or more nationwide permit(s) to authorize the work described in this notification. I certify that this information in this pre-construction notification 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 Pre-Construction Notification must be signed by the person who desires to undertake the proposed activity (applicant) and, if the statement in block 11 has been filled out and signed, the authorized agent.

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.

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