Sample Joint Application - Pennsylvania

3150-PM-BWEW0036A

Rev. 3/2022

COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
and
DEPARTMENT OF ARMY CORPS OF ENGINEERS
(Pittsburgh, Baltimore, Philadelphia and Districts)

JOINT APPLICATION FOR
PENNSYLVANIA CHAPTER 105 WATER OBSTRUCTION AND ENCROACHMENT PERMIT AND
U.S. ARMY CORPS OF ENGINEERS SECTION 404 PERMIT

Before completing this form, please read the step-by-step instructions
and Section F Application Completeness Checklist provided with this Joint Permit package.
AGENCY USE ONLY
Application ID# (Assigned by DEP)

RECEIVED DATE

CHECK NO.

Program Application No.

REQUIRED APP. FEE

AMOUNT $

SECTION A.

APPLICATION TYPE

SECTION B.

APPLICANT IDENTIFIER

STANDARD

SMALL PROJECTS

Applicant Name

Employer ID# (EIN)

Consulting Firm

Employer ID# (EIN)

SECTION C.

PROJECT LOCATION DATA AND STATUS

Name of stream and/or body of water and Chapter 93 designation.
Corps District where project will occur.
Pittsburgh (Ohio River Basin)

Baltimore (Susquehanna River Basin)

Philadelphia (Delaware River Basin)

Name of the U.S.G.S. 7 1/2 Minute Quadrangle Map where project is located:
Indicate location of project: Latitude

; Longitude

Project type, purpose and need:

HAS ANY PORTION OF PROPOSED PROJECT BEEN AUTHORIZED?

yes

no

date authorized

If yes, attach description of those portions of the project that have been authorized and identify dates of authorization.
SECTION D.

AQUATIC RESOURCE IMPACT TABLE

HAS ALL INFORMATION INCLUDED ON THE IMPACT TABLE BEEN PROVIDED?

yes

no

If NO, indicate the information not included and the reason. Also attach a completed AQUATIC RESOURCES IMPACT TABLE
(3150-PM-BWEW0557) worksheet or equivalent.
- Project Information:
- Corps / 404:
- DEP / 105:

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3150-PM-BWEW0036A

SECTION E.

Rev. 3/2022

COMPLIANCE REVIEW

Place an "X" in either the YES or NO block for each section below to indicate if applicant (owner and/or operator) are currently
in violation pertaining to each question.
Yes

Yes

No

No

Is the applicant (owner and / or operator) currently in violation of any permit, authorization or approval issued by
the Department?
If YES – complete the necessary information for questions 1 - 3.
1.
2.

Permit Number:
Nature of the violation(s) (if any):

3.

Status of violation(s) (i.e., schedule for compliance, etc.):

Is the applicant in violation of the, the Dam Safety and Encroachments Act, Chapter 105 Dam Safety and
Waterway Management regulations or other laws administered by the Department, PA Fish and Boat Commission
or a river basin commission such as the Susquehanna River Basin Commission (SRBC), the Delaware River
Basin Commission (DRBC) or the Ohio River Valley Water Sanitation Commission (ORSANCO)?. This includes
a violation of an adjudication and order, agreement, consent order or decree, whether or not the applicant’s
violation resulted in an order or civil penalty assessment.
If YES – complete the necessary information for questions 1 – 2.
Use additional sheets of paper, if required, and attach to application
1.

Nature of the violation(s) (if any):

2.

Status of violation(s) (i.e. schedule for compliance, etc.):

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3150-PM-BWEW0036A

SECTION F.

Rev. 3/2022

APPLICATION COMPLETENESS CHECKLIST

Applicant must place an entry - Y = Yes, N = No, N/A = Not Applicable - in each left side column space. See Section 105.13
for additional details. If you are applying under the Small Projects Application format, place an entry in only those comments
prefixed by an asterisk (*).
REQUIREMENT

Applicant Entry

a. GIF and permit application properly signed, sealed and witnessed

*

b. Application Fee & Worksheet enclosed (see Section G.)

*

c.

*

Copies and proof of receipt - Act 14 notification - Acts 67/68/127

d. Cultural Resource Notice (Notice, return receipt and PHMC review letter, as
appropriate)

*

e. Pennsylvania Natural Diversity Inventory (signed PNDI Receipt showing
Avoidance Measures or Potential Impacts and proof of delivery to the
appropriate jurisdictional agency(ies) where further coordination is required,
as appropriate)

*

f.

*

Plans (site plan including cross sections and profiles for Subsections 151,
191, 231, 261)

g. Location map
h. Project description narrative including PNDI avoidance measures (if
applicable)
AND Aquatic Resource Impact Table

*
*

i.

Color photographs with map showing location taken

*

j.

Environmental Assessment form

*

k.

Erosion and Sediment Control Plan and approval letter

l.

Hydrologic and hydraulic analysis

m. Stormwater Management Analysis with consistency letter
n. Floodplain Management Analysis with consistency letter
o. Risk Assessment
p. Professional engineer’s seal and certification

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DEP Use Only

3150-PM-BWEW0036A

SECTION G.

Rev. 3/2022

DETERMINATION OF APPLICATION FEES (DEP FEES ONLY)

The fee required for a project authorized under this permit shall be consistent with 25 PA Code §105.13 (relating to regulated
activities – information and fees). To determine the application fee, please complete the Chapter 105 Fee(s) Calculation
Worksheet (3150-PM-BWEW0553). Please provide the completed worksheet and a check for the applicable fee(s) made
payable to the “Commonwealth of Pennsylvania Clean Water Fund.”
SECTION H.

ADJOINING PROPERTY OWNERS

Please list the name and address of all property owners whose land adjoins the project property.
NAME

ADDRESS

SECTION I. CERTIFICATION AND SIGNATURE (see Instructions for clarification of signature requirements)
I certify under penalty of law that the information provided in this permit registration is true and correct to the best of my
knowledge and information and that I possess the authority to undertake the proposed action. I am aware that there are
significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.
(If any of the information and/or plans is found to be in error, falsified, and/or incomplete, this authorization/verification may be
subject to modification, suspension, or revocation in accordance with applicable regulations.)
I certify that the project proposed in this application complies with and will be conducted in a manner that is consistent with the
approved Coastal Zone Management program of the Commonwealth of Pennsylvania. (Only portions of Erie, Bucks,
Philadelphia and Delaware Counties are in the Coastal Zone).
I grant permission to the agencies responsible for authorization of this work, or their duly authorized representative, to enter
the project site for inspection purposes during working hours. I will abide by the conditions of the permit or license if issued
and will not begin work without the appropriate authorization.

Signature of Applicant/Owner

Date

Typed / Printed Name & Title of Applicant/Owner

Signature of Witness

SEAL

Typed / Printed Name & Title of Witness

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