1. CHAPTER 105 WATER OBSTRUCTIONS AND ENCROACHMENT

3150-PM-BWEW0500 Rev. 8/2016  COMMONWEALTH OF PENNSYLVANIA
Form  DEPARTMENT OF ENVIRONMENTAL PROTECTION
  BUREAU OF WATERWAYS ENGINEERING AND WETLANDS
 

 

 

3150-PM-BWEW0500 Rev. 8/2016  COMMONWEALTH OF PENNSYLVANIA

Form  DEPARTMENT OF ENVIRONMENTAL PROTECTION

  BUREAU OF WATERWAYS ENGINEERING AND WETLANDS

 

 

 

3150-PM-BWEW0500 Rev 8/2016

Form

 

 

3150-PM-BWEW0500 8/2016

Form

 


CHAPTER 105 WATER OBSTRUCTIONS AND ENCROACHMENT
GENERAL PERMIT REGISTRATION
 
PLEASE MARK (“X”) ALL THAT APPLY:

 GP- 1  Fish Habitat Enhancement Structures

 GP- 2  Small Docks & Boat Launching Ramps
 
Please mark (“X”) the specific type of project:

 private recreational dock

 public access facility

 public service facility

 other private or commercial facility

 GP- 3  Bank Rehabilitation, Bank Protection and Gravel Bar Removal

 GP- 4  Intake and Outfall Structures
 

 GP- 5  Utility Line Stream Crossing

 GP- 6  Agricultural Crossings & Ramps
 GP- 7  Minor Road Crossings
 GP- 8  Temporary Road Crossings
 GP- 9  Agricultural Activities
 GP-10  Abandoned Mine Reclamation
 GP-11  Maintenance, Testing, Repair, Rehabilitation, or Replacement of Water Obstructions and Encroachments (reviewed by DEP Regional Office only)
 GP-15  Private Residential Construction in Wetlands
   Activity Related to Oil and Gas Exploration, Production or Transmission

  Activity Subject to FERC approval (Docket number      )     FERC Natural Gas Act Facility

SECTION A. APPLICANT INFORMATION
Applicant’s Name / Client

     
DEP Client ID# (if known)
     
Employer ID# (EIN)
     
Client Information - Please select Client Type / Code from drop down box under the correct entity shown to the right.
(or may be written in)  →
Government
Non-Government
Individual
 
 
 
 
Mailing Address
     
City
     
State
     
ZIP + 4
     
Contact Person – Last Name  First  MI  Suffix
                        
Telephone
(     )      
Email Address
     
SECTION B. CONSULTANT INFORMATION (Complete if different than above)    N/A
Contact Person – Last Name  First  MI  Suffix
                        
Consultant’s Title
     
Consulting Firm
     
Mailing Address

     

City
     
State
     
ZIP + 4
     
Telephone
(     )      
Fax
(     )      
Email
     
Employer ID# (EIN)
     
SECTION C. PROJECT INFORMATION
Project /Site Name:
     
DEP Site ID# (if known or leave blank)
     
Client Relationship - Please select Site-to-Client Relationship / Code from drop down box to the right. (or may be written in)  →
Double-click on shaded area below to select correct Site-to-Client Relationship / Code ↓
County
     
Municipality   City   Borough   Township
       
 
Site Location / Address
     
City
     
State
     
ZIP + 4
     
Collection Method:    EMAP    HGIS    GISDR*    ITPMP    GPS    WAAS    LORAN
Check the horizontal reference datum (or projection datum) employed in the collection method.
 EMAP and HGIS (PNDI) have known datum and do not require checking here.   NAD27   NAD83   WGS84 (GEO84)
Enter the date of collection if coordinates were derived from GPS, WAAS or LORAN.       mm       dd       yyyy
Applicant’s Name

     

GENERAL PERMIT REGISTRATION
 
 
SECTION D. RESOURCE IDENTIFICATION
Please place an “X” in the appropriate box to indicate if the applicant has identified that any of these resources may be present at the project site; indicate that no resources were identified or indicate and list those resources which were identified.

Each General Permit (GP) has a specific set of restrictions and some resources may require certain actions or prohibit the project from being eligible to register use of the GP.

Applicant Entry
DEP Use Only
No resources identified as being present at the project site …………………………………….
 
   
Resources identified as being present at the project site:
   
-        
   
-        
   
-        
   
SECTION E. REGISTRATION CHECK LIST AND REQUIREMENTS
Please place an “X” next to each item (1 - 16) to ensure it is completed and/or provided.

Unless otherwise specified, all items are required to ensure a complete Registration package.

**Provide ONE (1) ORIGINAL and ONE (1) COPY of the Registration package**

Applicant Entry
DEP Use Only
1.  General Permit Registration form properly completed and signed:
   
- I have read the terms and conditions of the GP(s) indicated above  
   
2.  Permit Fee:
   
- General Permit Registration Fee  
   
- Chapter 105 Fee Calculation Worksheet  
   
3.  Notification sent to the Municipality & County: (copy of General Permit Registration form)
   
4.  PASPGP-5 Reporting Criteria Checklist properly completed:
   
5.  Location Map (USGS quad map) with project site marked:
   
6.  Color Photographs with dates and descriptions: (see instructions)    N/A
 
   
7.  Stream Name and Chapter 93 Classification: (example: UNT to #40637 HOUSE RUN, HQ-WWF/EV)
   
       
   
8.  Project Description:
   
- Project Description including PNDI avoidance measures (if applicable)  
   
- Aquatic Resource Impacts Table  
   
9.  Site Specific and/or Standard Drawings depicting the project’s GP activities.
   
10.  Site Plan depicting the site of the project’s GP activities. (see Section F.)
   
11.  Erosion & Sediment Control Plan (E&S Plan) (required for GP-11 only - see instructions)
   
12.  Written Directions to Project Site:
   
-        
   
-        
   
-        
   
13.  Pennsylvania Natural Diversity Inventory (PNDI):

 Please place an “X” next to the appropriate box indicating the information provided:

   
Signed PNDI Receipt showing:
   
- “No Known Impacts”  
   
- “Avoidance Measures” which have ALSO been incorporated into the project description.  
   
- “Potential Impacts” AND proof of delivery to the appropriate agency(ies) where further coordination is required.  
   

 

Applicant’s Name

     

GENERAL PERMIT REGISTRATION
 
 

Please place an “X” next to each item (1 - 16) to ensure it is completed and/or provided. (continued)
Applicant Entry
DEP Use Only
14.  Bog Turtle Habitat Screening:

Please place an “X” next to the appropriate box indicating the information provided:

   
- Completed Request for a Bog Turtle Habitat Screening Form  
   
- “No Effect” determination from the Army Corp of Engineers  
   
- Documented clearance from the US Fish and Wildlife Services  
   
- N/A due to GP type, wetland impact and/or County of project  
   
15.  Activities which impact wetlands:

Please place an “X” next to the appropriate box indicating the information provided:


- N/A because no wetland impacts are proposed or no compensatory mitigation is necessary.
- A wetland delineation with complete data sheets in accordance with the 1987 Corps of Engineers Wetland Delineation Manual AND the appropriate Regional Supplements to the Corps of Engineers Wetland Delineation Manual for use in Pennsylvania.  
- If direct or indirect wetland impacts are greater than 0.05 acres, a compensatory mitigation plan in accordance with the Department’s Replacement criteria which provides compensation at a minimum one to one acre ratio.  
- If compensatory mitigation onsite is determined not feasible:
A check, number      , in the amount of $      payable to the National Fish and Wildlife Foundation, N.A. 1237, as compensatory mitigation for       acres of impact in wetlands, in accordance with the Pennsylvania Wetland Replacement Project.  
   
     
     
     
     
16.  Registration of a GP-11:

Please place an “X” next to the appropriate box indicating the worksheet(s) provided:

   
- N/A because not registering use of GP-11  
   
- E&S Plan  
   
- Bridge and/or Culvert Replacement Projects or Projects That Change the Waterway Opening
   

SECTION F. SITE PLAN

Please place an “X” next to the appropriate box indicating what is shown on the site plan. Unless otherwise specified in the permit, all items are required to ensure a complete Registration package.
Applicant Entry
DEP Use Only
All items included on Site Plan  
   
Items not included on Site Plan and reason:
   
-        
   
-        
   
-        
   

SECTION G. IMPACT TABLE

Please place an “X” next to the appropriate box indicating what is shown on the Impact Table. The Aquatic Resource Impact Table (3150-PM-BWEW0557) worksheet or equivalent is required.
Applicant Entry
DEP Use Only
All information included on Impact Table  
   
Information not included on Impact Table and reason:
   
- Project Information:        
   
- Corps / 404:        
   
- DEP / 105:        
   

·  

Applicant’s Name

     

GENERAL PERMIT REGISTRATION
 
 

 

SECTION H. CERTIFICATION
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.)

          
 Signature of Applicant/Owner  Date


       
 Typed / Printed Name
       
 Typed / Printed Title

PA Fish and Boat Commission Approval (for GP-1 only)

          
 Signature of Reviewer  Date
             (     )        
 Reviewer’s Typed / Printed Name  Phone Number
                
 Reviewer’s Typed / Printed Title  Email Address

This General Permit shall not be effective until the owner has had their E&S Plan reviewed by the appropriate Regional Office or District, obtained Federal Authorization and, where required, obtained an SLLA from DEP.

AN ACKNOWLEDGED COPY OF THIS GENERAL PERMIT REGISTRATION PACKAGE (INCLUDING THE ACKNOWLEDGEMENT LETTER AND TERMS AND CONDITIONS), REQUIRED FEDERAL AUTHORIZATION,
AND THE E&S PLAN MUST BE AVAILABLE AT THE PROJECT SITE DURING CONSTRUCTION.

SECTION I. ACKNOWLEDGEMENT – DEP USE ONLY
Signatures authorizing acknowledgment to use and register:

A.   Completeness Review:

 

DEP / District Reviewer Signature

             

Reviewer’s Typed / Printed Name

 

Begin Date:

Incomplete Date:

Response Date:

End Date:

 

     

     

     

       

 

Completeness Status

 

  YES   NO

 

B.   Eligibility Review:

  

DEP / District Reviewer Signature

         

Reviewer’s Typed / Printed Name

 

Begin Date:

Incomplete Date:

Response Date:

End Date:

 

     

     

     

     

 

 

Deficient - DENIED

 

 

C.   Decision Review:

 

DEP / District Manager Signature

         

Reviewer’s Typed / Printed Name

 

 

 

Begin Date:

End Date:

 

 

 

     

     

 

Disposition Status

 

 

 

 

 

WITHDRAWN

RETURNED

 APPROVED

 DENIED

 

E.   Contact Information:

         (     )                 

 Typed / Printed Name  Phone Number  Email Address

 

F.   Permit Tracking:

Received        Acknowledged        SLLA required: NO YES  PASPGP-5: NO YES REP

NONREP

GP -          GP -          GP -          GP -          GP -        


Notes:      

 

 
 

 
 

 
 

 
 

 

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