1. CHAPTER 105 WATER OBSTRUCTIONS AND ENCROACHMENT
    2. GENERAL PERMIT REGISTRATION

3150-PM-BWEW0500
Rev. 8/2016
COMMONWEALTH OF PENNSYLVANIA
Form
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WATERWAYS ENGINEERING AND WETLANDS
- 1 -
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

3150-PM-BWEW0500
Rev 8/2016
Form
- 2 -
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............................................................................................................

3150-PM-BWEW0500
8/2016
Form
- 3 -
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:

3150-PM-BWEW0500
8/2016
Form
- 4 -
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
D. Contact Information:
(
)
Typed / Printed Name
Phone Number
Email Address
E. Permit Tracking:
Received
Acknowledged
SLLA required:
NO
YES PASPGP-5:
NO
YES
REP
NONREP
GP -
GP -
GP -
GP -
GP -
Notes:

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