3150-PM-BWEW0036A Rev. 8/2016
    COMMONWEALTH OF PENNSYLVANIA
    DEPARTMENT OF ENVIRONMENTAL PROTECTION
    and
    DEPARTMENT OF ARMY CORPS OF ENGINEERS
    (Baltimore, Philadelphia, and Pittsburgh Districts)
    JOINT APPLICATION FOR
    PENNSYLVANIA CHAPTER 105 WATER OBSTRUCTION AND ENCROACHMENT PERMIT AND
    U.S. ARMY CORPS OF ENGINEERS SECTION 404 PERMIT
    - 1 -
    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)
    Program Application No.
    RECEIVED DATE
    CHECK NO.
    REQUIRED APP. FEE
    AMOUNT $
    SECTION A.
    APPLICATION TYPE
    STANDARD
    SMALL PROJECTS
    SECTION B.
    APPLICANT IDENTIFIER
    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 Resource Impact Table
    (3150-PM-BWEW0557)
    worksheet or equivalent.
    - Project Information:
    - Corps / 404:
    - DEP / 105:

    3150-PM-BWEW0036A Rev. 8/2016
    - 2 -
    SECTION E.
    COMPLIANCE REVIEW
    Yes
    No
    Is the applicant (owner and/or operator) currently in violation of any permits issued by the Department?
    If yes, please provide:
    1.
    Permit Number:
    2.
    Nature of the violation (if any):
    3.
    Status of violation (i.e., schedule for compliance, etc.):
    SECTION F.
    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
    DEP Use Only
    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. PASPGP-5 Reporting Criteria Checklist
    *
    f.
    Bog Turtle Habitat Screening (copy of “No Effect” determination from the Army
    Corps of Engineers OR copy of documented clearance from the US Fish and
    Wildlife Service)
    *
    g. 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)
    *
    h. Plans (site plan including cross sections and profiles for Subsections 151, 191,
    231, 261)
    *
    i.
    Location map
    j.
    Project description narrative including PNDI avoidance measures (if applicable)
    AND Aquatic Resource Impact Table
    *
    *
    k. Color photographs with map showing location taken
    *
    l.
    Environmental Assessment form
    *
    m. Erosion and Sediment Control Plan and approval letter
    n. Hydrologic and hydraulic analysis
    o. Stormwater Management Analysis with consistency letter
    p. Floodplain Management Analysis with consistency letter
    q. Risk Assessment
    r.
    Professional engineer’s seal and certification
    s. Alternative analysis
    t.
    Mitigation plan

    3150-PM-BWEW0036A Rev. 8/2016
    - 3 -
    SECTION G.
    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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