1. PASPGP-5 REPORTING CRITERIA CHECKLIST

- 1 -
3150-PM-BWEW0051
Rev. 8/2016
Checklist
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WATERWAYS ENGINEERING AND WETLANDS
DEP USE ONLY
Non-Reporting
Reporting
PASPGP-5 REPORTING CRITERIA CHECKLIST
The following questionnaire must be completed (instructions on pages 1-6) and submitted as part of all DEP
Chapter 105 applications / registrations to determine the appropriate Federal Pennsylvania State Programmatic
General Permit-5 (PASPGP-5) review procedure.
Incomplete submissions, including lack of certification
signature, will be returned.
Applicant / Project Name:
County(s):
SECTION A: ELIGIBILITY DETERMINATION
YES
NO
1.
Does the proposed work associated with the Single and Complete Project temporarily and/or
permanently impact greater than 1.0 acre of waters and/or wetlands, and/or result in the loss of greater
than 1,000 linear feet of stream channel(s)?
YES
NO
2.
Is any of the proposed work located waterward of the ordinary high water mark (OHWM) of any of the
ineligible waterbodies identified in the instructions?
YES
NO
3.
Has any portion of the proposed work been denied a DEP Chapter 105 Permit, a State Water Quality
Certification as required under Section 401 of the Clean Water Act, or a Coastal Zone Consistency
Determination?
YES
NO
4.
Does the proposed work result in the diversion of more than 10,000 gallons per day of surface water or
groundwater into or out of the Great Lakes Basin (Lake Erie Watershed)?
*****
SECTION B: REPORTING ACTIVITY DETERMINATION
YES
NO
1.
Does the proposed work associated with a Single and Complete Project, including any attendant
features, permanently and/or temporarily impact greater than 0.5 acre of waters of the United States,
including jurisdictional wetlands?
YES
NO
2a. Does the application/registration include any proposed Single and Complete Projects permanently
impacting greater than 250 linear feet of streams, rivers, or other watercourses (excluding wetlands)?
YES
NO
2b. Is the Single and Complete Project for stream bank stabilization, rehabilitation, protection and/or
enhancement and propose impacts of greater than 500 linear feet of stream channel(s)?
YES
NO
2c. Does the Single and Complete Project qualify for DEP GP-1 for Fish and Enhancement Structures?
YES
NO
2d. Is the project covered by a programmatic State Water Quality Certification issued by DEP - that is
conditioned upon receiving approval by- the Environmental Review Committee?
YES
NO
3.
Does the application/registration include any Single and Complete Projects that propose the permanent
conversion of greater than 0.10 acre of forested and/or shrub-scrub wetlands in association with a
regulated activity?
YES
NO
4.
If the application/registration is for a utility line, do any of the single and complete projects in waters of
the United States, including jurisdictional wetlands, exceed 500 linear feet (excluding overhead lines)?
YES
NO
5.
Is this application/registration to place a buried utility line in waters and/or wetlands in a manner that the
utility line will run parallel to or along a stream bed?

3150-PM-BWEW0051
Rev. 8/2016
Checklist
- 2 -
SECTION B: REPORTING ACTIVITY DETERMINATION (CONT)
YES
NO
6.
Is the application/registration associated with a Single and Complete Project whereby a previous
Department of the Army authorization has been issued through an Individual Permit, a Nationwide Permit,
or a PASPGP processed by the Corps as a Category III/Reporting Activity?
If YES, please complete the
following table.
Authorization
Type
Authorization
Number
Date
(mm/dd/yyyy)
Federal Permitted Impacts
Wetlands
Waters
YES
NO
7a. Is the proposed project located in waterways occupied by Federally listed, proposed, or candidate
mussels or fish, or in waters of the United States within 300 feet of these listed waterways?
See
instructions for list of waterways.
YES
NO
7b. If 7a is yes, have you received documented clearance from the USFWS, or a Section 7 of the Endangered
Species Act (ESA) “no effect” determination from the Corps? Documented clearance from the USFWS
could include PNDI language stating “NO KNOWN IMPACT”; or, if in a USFWS letter the language must
indicate “no effect” or “the project or activity will not affect Federally listed species.”
YES
NO
8a. Does the project propose impacts to Federally regulated wetlands in a county that requires bog turtle
screening procedures?
See instructions for list of counties.
YES
NO
8b.
If 8a is YES, have you received documented clearance from the USFWS, or a Section 7 ESA “no effects”
determination from the Corps? Documented clearance from the USFWS could include PNDI language
stating “NO KNOWN IMPACT”; or, if in a USFWS letter the language must indicate “no effect” or “the
project or activity will not affect Federally listed species.”
YES
NO
9a. Does the completed Pennsylvania Natural Diversity Inventory (PNDI) search receipt identify a potential
conflict(s) for a Federally listed species?
YES
NO
9b. If YES for 9a, have you received additional documented Section 7 ESA clearance, or do you agree,
through signing of the PNDI receipt, to comply with all avoidance measures identified on the PNDI receipt
associated with Federally listed species for the proposed work?
YES
NO
10.
Is the proposed work associated with maintenance dredging of a reservoir’s design storage capacity,
including the removal of accumulated sediments? This corresponds to activities authorized pursuant to
Section 7 of the Dam Safety and Encroachments Act (DSEA), 32 P.S. § 693.1, et seq., and the rules and
regulations promulgated there under in the PA Bulletin (codified at 25 PA. Code, Chapter 105, §
105.131(c)).
YES
NO
11a. If the DEP Chapter 105 application/registration requires submittal of a Cultural Resources Notification
Form as part of the application/registration, have you included the response letter from the State Historic
Preservation Officer (SHPO), i.e., Pennsylvania Historic and Museum Commission (PHMC) with your
application/registration?
YES
NO
11b. Has the PHMC determined that archaeological or other cultural resources are believed to exist within the
permit area?
YES
NO
11c. If yes for 11b, have you received follow-up documented clearance from PHMC, or a Section 106 “no
effect” determination from the Corps?
YES
NO
12a. Does the proposed work 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?
See
instructions for listing.
YES
NO
12b. If yes for 12a, have you received a written determination from the Federal agency with direct management
responsibility for such river that the proposed activity will not adversely affect any Wild and Scenic River
including study rivers?
YES
NO
13. Does the proposed project require the preparation of an Environmental Impact Statement?
YES
NO
14. Does the proposed regulated activity or area of indirect impact (secondary impact) extend across state
boundaries (i.e., the work in not wholly located within the Commonwealth of Pennsylvania)?

3150-PM-BWEW0051
Rev. 8/2016
Checklist
- 3 -
SECTION B: REPORTING ACTIVITY DETERMINATION (CONT)
YES
NO
15. Is the proposed work authorized pursuant to DEP Chapter 105 permits in conjunction with coal and non-
coal mining permits issued by the DEP District Mining Offices (Bureau of Mining and Reclamation),
including activities authorized pursuant to Chapter 105 Waiver 4 [25 Pa. Code §105.12(a)(4)] and GP-101
and GP-102]?
YES
NO
16. Is the proposed work associated with the construction of a Mitigation Bank or In Lieu Fee site developed
to meet the requirements of the Corps and EPA April 10, 2008 Compensatory Mitigation for Losses of
Aquatic Resources: Final Rule?
YES
NO
17. Will the proposed work alter, use, build upon, attempt to possess, or that may harm or impair any existing
or proposed Corps Civil Works project, and any Corps-owned or managed property?
YES
NO
18a. Does the Single and Complete Project involve the construction or expansion of a residential, commercial
or institutional subdivision or development?
YES
NO
18b. Does greater than 0.25 acre of wetland(s) exist within the property boundary that are not proposed to be
directly impacted as part of this application/registration?
If YES, provide wetland acreage:
acres.
YES
NO
18c. Are you proposing to protect the wetland area(s) through a deed restriction or conservation easement that
follows the Corps’ Model Protective Covenant?
YES
NO
19. Does the proposed work temporarily impact waters and/or wetlands that will remain in place for more than
1 year?
YES
NO
20. Do you have any other pending applications/registrations with the DEP or Corps that are necessary for
this total proposed project to function and meet its intended purpose?
If YES, provide following
information.
Application / Registration
Number / Type
Project Name
Date of
Submittal to
DEP
(mm/dd/yyyy)
DEP / CCD
Reviewing
Office
Corps
Reviewing Office
YES
NO
21. Are you proposing to do work in the Delaware River (upstream from the U.S. Route 202 Bridge in New
Hope, Pennsylvania.) and/or the Lehigh River (from the mouth to Francis E. Walter Dam, located in
Carbon and Luzerne County, Pennsylvania between March 15 and June 30?
YES
NO
22a. Does the proposed work occur in any of the waters listed in the instructions?
YES
NO
22b. Will you comply with all of the identified conservation measures?
*****

3150-PM-BWEW0051
Rev. 8/2016
Checklist
- 4 -
SECTION C: CERTIFICATION
I certify that the information provided on this form is true and correct to the best of my knowledge and information.
If any
of the information and/or plans is found to be in error, falsified, and/or incomplete, your Chapter 105/PASPGP-5
authorization/verification may be subject to modification, suspension, or revocation in accordance with applicable regulations.
Signature of Applicant
Date
Name Typed or Printed
*****
IMPERVIOUS SURFACE DATA FOR CORPS
YES
NO
1a. Is your project located in the Corps of Engineers Philadelphia District (Delaware River Watershed), or in
Chester, Lancaster, or York County?
YES
NO
1b. Does your project propose impervious surfaces within waters and wetlands?
If YES, provide area of
impervious surface within the footprint of waters and wetlands:
square feet
YES
NO
1c. Does any part of your project propose the removal of any impervious surfaces?
If YES, provide area of
impervious surface being removed:
square feet
FOR DEP USE ONLY
DEP / District Manager Signature
Date
Name Typed or Printed
Permit Number

Back to top