1. EXHIBIT A
      2. PENNSYLVANIA OFFICES
      3. EXHIBIT B
      4. U.S. ARMY CORPS OF ENGINEERS DISTRICT OFFICES
      5. DEPARTMENT OF ENVIRONMENTAL PROTECTION REGIONAL OFFICES
    1. CHAPTER 105 FEE(S) CALCULATION WORKSHEET
    2. PART ONE: WATER OBSTRUCTIONS AND ENCROACHMENTS
      1. SECTION A. APPLICATION FEES
      2. SECTION B. OTHER FEES
    3. PART TWO: DAM SAFETY (USE ONE FEE SHEET PER DAM)
      1. SECTION A. APPLICATION FEES
      2. SECTION B. OTHER FEES
      3. GP Fee Explanation (#):
      4. Water Obstruction and Encroachment Examples:
      5. Dam Safety Examples:
      6. INSTRUCTIONS FOR COMPLETING THE PASPGP-5 REPORTING CRITERIA CHECKLIST
      7. PASPGP-5 REPORTING CRITERIA CHECKLIST

3150-PM-BWEW0510
Rev. 6/2013
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WATERWAYS ENGINEERING AND WETLANDS
- 1 -
GENERAL PERMIT
BWEW-GP-10
ABANDONED MINE RECLAMATION
1. GENERAL DESCRIPTION AND AUTHORITY - The Department of Environmental Protection hereby
authorizes, by general permit, subject to the terms and criteria set forth below, the construction, operation or
maintenance of an encroachment or water obstruction for reclamation of an abandoned mining site, where the
Department has issued a notice of intent to forfeit the bond for a mining activity permitted after August, 1977
and before July, 1982. This authorization is under Section 7 of the Dam Safety and Encroachments Act,
(32 P.S. §693.7) and the rules and regulations promulgated thereunder at 25 Pa. Code §§105.441 - 105.449.
2.
DENIAL OF AUTHORIZATION - The Department shall have the discretion, on a case-by-case basis, to deny,
revoke or suspend the authorization to use this general permit for any project which the Department
determines to have a substantial risk to life, property or the environment or otherwise could not be adequately
regulated by the provisions of this general permit.
3.
SITES AND CONDITIONS WHERE THIS GENERAL PERMIT DOES NOT APPLY - This General Permit does
not apply and is not valid in the following situations:
a
Projects located where there would be an impact on species of special concern listed under the
Endangered Species Act of 1973, the Wild Resources Conservation Act, the Fish and Boat Code or the
Game and Wildlife Code. Records regarding species of special concern are maintained in a computer
database called the “Pennsylvania Natural Diversity Inventory” (PNDI). To verify that there will be no
such impacts for a specific project, complete the Pennsylvania Natural Diversity Inventory (PNDI) Form
and submit it to the person conducting the online PNDI Project Planning and Environmental Review
Tool search. This person performing the search could be someone from DEP, the County Conservation
Districts, or a consultant. Alternatively, if you plan to conduct the PNDI online search yourself – a
search form is not needed prior to the PNDI online search.
After conducting a PNDI online search, if your PNDI Project Environmental Review Receipt has
"Potential Impacts," DEP and the jurisdictional agencies require that you submit additional information to
the agencies noted on the Receipt for further review. Please send a copy of the PNDI Receipt, a
completed PNDI Form, and a USGS 7.5 minute quadrangle map with project boundaries delineated on
the map to the agencies referenced on your PNDI Reciept.
b.
Construction activities in stocked trout streams from March 1 through June 15, wild trout streams from
October 1 through December 31 and Lake Erie tributaries from September 1 through December 1,
unless approval is obtained from the Pennsylvania Fish and Boat Commission's Division of
Environmental Services (see “Exhibit A”). Stocked and wild trout stream locations are compiled by the
Commission's Division of Fisheries Management (see “Exhibit A”).
4.
DEFINITIONS - The terms as used in this General Permit shall have the following meanings:
BODY OF WATER - A natural or artificial lake, pond, reservoir, swamp, marsh or wetland.
OWNER - Any person who owns, controls, operates, maintains, or manages a dam or reservoir, water
obstruction, or encroachment.
PERSON - Any natural person, partnership, association, corporation, public utility, municipality, municipal
authority, political subdivision of the Commonwealth, receiver or trustee and any department, board,
commission or authority of the Commonwealth.
RECLAMATION - Those actions set forth in the forfeiting operators permit taken to restore the area affected by
surface and underground mining activities as required by 25 Pa. Code Chapters 86-89 and for which State
and/or Federal reclamation funding is used to perform the reclamation.

3150-PM-BWEW0510
Rev. 6/2013
- 2 -
REGULATED WATERS OF THE COMMONWEALTH - All watercourses, streams or bodies of water and their
floodways wholly or partly within or forming part of the boundary of this Commonwealth.
RESERVOIR - Any basin, either natural or artificial, which contains or will contain the water or other fluid or
semifluid impounded by a dam.
STOCKED TROUT STREAM - A stream classified as approved trout waters by the Fish and Boat
Commission. For current designations of stocked trout streams contact the Division of Fisheries Management
(see “Exhibit A”).
WATERCOURSE - Any channel or conveyance of surface water having defined bed and banks, whether
natural or artificial, with perennial or intermittent flow.
WETLANDS - Those areas that are inundated or saturated by surface or groundwater at a frequency and
duration sufficient to support, and that under normal circumstances do support, a prevalence of vegetation
typically adopted for life in saturated soil conditions, including swamps, marshes, bogs and similar areas.
WILD TROUT STREAMS - A stream classified as supporting reproducing trout populations by the Fish and
Boat Commission. For current designations of wild trout streams, contact the Division of Fisheries
Management (see “Exhibit A”).
5.
OTHER PERMITS - Nothing in this General Permit relieves the owner(s) of the obligation of complying with all
Federal, Interstate Compact and State laws, regulations and standards for the construction, operation or
maintenance of the activities covered by this General Permit.
6.
REGISTRATION FOR USE - Prior to construction, the owner(s) shall submit two copies of the completed
Notification to Use (“Exhibit D”) along with two copies of the location map and processed PNDI to the
Permitting and Technical Services Section or the County Conservation District (“Exhibit B” and “Exhibit C”).
The notification must be sent to the County Conservation District only if there is a delegation agreement
between the Department and the District. A copy of “Exhibit D” shall also be sent to the municipality and
county in which the work will be performed. The owner(s) may not begin work until he has received an
acknowledgement from the Permitting and Technical Services Section or County Conservation District that the
“Exhibit D” notification has been received and registered.
7.
FEES - The fee required for a project authorized under this General Permit shall be consistent with 25 PA
Code §105.13 (relating to regulated activities – information and fees).
8.
EFFECTIVE TIME PERIOD - This General Permit will remain in effect indefinitely unless specifically modified,
suspended or revised by the Department.
9.
SUSPENSION, MODIFICATION OR REVOCATION - The Department may suspend, modify or revoke this
General Permit at any time upon notice in the Pennsylvania Bulletin.
10. PROJECT INTERFERENCE - This General Permit does not authorize any interference with any existing or
proposed local, State, Federal or Federally licensed project, and permittee shall not be entitled to
compensation for damage or injury to the work authorized herein which may be caused by or a result of
existing or future operations undertaken by the United States or the Commonwealth of Pennsylvania or its
Political Subdivisions in the public interest.
11. CONDITIONS
a.
Any archeological artifacts discovered during the performance of work authorized under this General
Permit must be adequately protected and their discovery promptly reported to the Bureau for Historic
Preservation, Pennsylvania Historical and Museum Commission, 400 North Street, Second Floor,
Harrisburg, PA 17120-0093, Telephone (717) 783-2891.

3150-PM-BWEW0510
Rev. 6/2013
- 3 -
b.
All excess fill or excavated and dredged material shall be deposited and immediately stabilized outside
floodways, floodplains, wetlands and other regulated waters of this Commonwealth. Waste materials,
scrap or excess construction materials shall be collected, stored and disposed of in accordance with the
Solid Waste Management Act (35 P.S §§6018.101 - 6018.1003) and the regulations promulgated
thereunder.
c.
Owner(s) shall investigate for drinking water intakes or reservoirs to public and private water supplies
within 5 miles downstream of the reclamation site and written notice shall be given at least 10 days prior
to construction to operators of such intakes or reservoirs. Owner(s) shall notify public and private water
supply operators and the Department immediately and no longer than 1 hour after an occurrence at the
reclamation site which results in the release of suspended solids and turbidity to the drinking water
supply, including both surface and groundwater sources, that maintain the quality or quantity of the
drinking water supply.
d.
Reclamation projects shall not extend beyond the reclamation site.
e.
During construction activities, all public and private property including existing vegetation, landscape
features and monuments within, along and adjacent to the work area, shall be protected and preserved
to the maximum degree possible. This shall include, but not be limited to, precautions taken to
minimize damage, erosion, injury, or destruction; prevent pollution; provide protection of all trees and
other woody plants; special care being taken to protect the natural vegetation and surroundings to
include all natural drainageways, ponds, lakes, swamps, woods and fields; and storage of materials in
such manner to prevent leaching which would be injurious to soils and to plants. Precautions should be
taken to prevent damage to pipes, conduits and other underground structures.
f.
The owners shall notify the Fish and Boat Commission's Regional Field Office Manager (see “Exhibit A”)
responsible for the County where the activities are proposed 10 days prior to start of construction.
Written notification is suggested. The project site shall at all times be available for inspection by
authorized officers and employees of the Fish and Boat Commission.
g.
Prior to the use of explosives in a watercourse or body of water, the permittee shall secure a written
permit from the Fish and Boat Commission, pursuant to the Fish and Boat Code, Act 1980-175,
30 Pa.C.S. 2906 (relating to permits for use of explosives). Requests should be directed to the Fish and
Boat Commission, Division of Environmental Services (see “Exhibit A”).
h. Prior to construction, approval must be obtained from the Fish and Boat Commission's Division of
Environmental Services for use of this project on reclamation sites bordering (1) stocked trout streams
from March 1 through June 15 and (2) wild trout streams from October 1 through December 31.
i.
All temporary road crossings of the regulated waters of the Commonwealth in areas unaffected by
mining activities shall be constructed in accordance with the design standards and conditions of General
Permit BWEW-GP-8.
j.
Prior to construction, the property owner of the abandoned mine site shall be sent, by certified mail, a
questionnaire inquiring whether there are existing facilities on site such as ponds, wetlands or diversion
ditches which the property owner wants left in place in their present condition. Construction may not be
commenced until receipt of the complete questionnaire.
12.
DEPARTMENT INSPECTION - As a condition of use of this General Permit, and of the owner's authority to
conduct the activities authorized by this General Permit, the owner hereby authorizes and consents to allow
authorized employees or agents of the Department or County Conservation District, without advance notice or
a search warrant, at any reasonable time and upon presentation of appropriate credentials, and without delay,
to have access to and to inspect all areas where the project is being constructed, operated or maintained. The
authorization and consent shall include consent to conduct tests or sampling, to take photographs, to perform
measurements, surveys and other tests, to inspect the methods of construction, operation or maintenance, to
examine and copy books, papers and records pertinent to any matter under investigation, and to take any
other action necessary to assure that the project is constructed, operated or maintained in accordance with the

3150-PM-BWEW0510
Rev. 6/2013
- 4 -
terms and criteria of the General Permit. This General Permit condition is referenced in accordance with
section 16 of the Dam Safety and Encroachments Act (32 P.S. §693.16) and in no way limits any other powers
granted under the Dam Safety and Encroachments Act.
13. ACTIVITIES NOT IN ACCORDANCE WITH THE TERMS OR CONDITIONS - If the Department or County
Conservation District determines, upon inspection, that the construction, operation or maintenance of a project
has violated the terms or criteria of this General Permit, the Chapter 105 and 102 Rules and Regulations or the
appropriate NPDES permit for discharge of stormwater from construction activities, the Department may take
such actions, legal or administrative, that it may deem to be appropriate.
14. PROPERTY RIGHTS - This General Permit does not convey any property rights, either in real estate or
material or in any exclusive privileges; nor does it authorize any injury to property or invasion of rights or any
infringement of Federal, State or local laws or regulations.
15. OTHER APPROVALS - The owners shall secure all other approvals that may be necessary under other
Federal, State or local laws or regulations.
16. EROSION AND SEDIMENT CONTROL PLAN - Work must be done in compliance with Chapter 102 (relating
to Erosion Control) and/or under the appropriate NPDES permit for discharge of stormwater from construction
activities. Prior to construction, an Erosion and Sediment Control Plan must be reviewed and determined
adequate by the County Conservation District in which the activities are proposed and implemented prior to,
during and after construction. The County Conservation District shall be notified ten (10) days prior to the start
of construction. The project site shall at all times be available for inspection by authorized employees of the
County Conservation District. The Erosion and Sediment Control Plan shall be available at the site.

3150-PM-BWEW0500A
9/2012
- 1 -
EXHIBIT A
PENNSYLVANIA OFFICES
PENNSYLVANIA FISH AND BOAT COMMISSION
Regional Headquarters Address
County Responsibility
Northwest Region
Regional Manager
Butler, Clarion, Crawford, Erie, Forest, Lawrence,
11528 Highway 98
Mercer, Venango and Warren
Meadville, PA 16335-7320
814-337-0444
Southwest Region
Regional Manager
Allegheny, Armstrong, Beaver, Cambria, Fayette,
236 Lake Road
Greene, Indiana, Somerset, Washington and
Somerset, PA 15501-1644
Westmoreland
814-445-8974
Northcentral Region
Regional Manager
Cameron, Centre, Clearfield, Clinton, Elk, Jefferson,
1150 Spring Creek Road
Lycoming, McKean, Montour, Northumberland,
Bellefonte, PA 16823
Potter, Snyder, Tioga and Union
814-359-5250
Southcentral Region
Regional Manager
Adams, Bedford, Blair, Cumberland, Dauphin,
1704 Pine Road
Franklin, Fulton, Huntingdon, Juniata, Lebanon,
Newville, PA 17241
Mifflin, Northumberland (Mahatango Creek in
717-486-7087
Jordan and Lower Mahanoy Townships only),
Perry and York
Southeast Region
Regional Manager
Berks, Bucks, Chester, Delaware, Lancaster,
P.O. Box 9
Lehigh, Montgomery, Northampton, Philadelphia
Elm, PA 17521
and Schuylkill
717-626-0228
Northeast Region
Regional Manager
Bradford, Carbon, Columbia, Lackawanna, Luzerne,
5566 Main Road
Monroe, Pike, Sullivan, Susquehanna, Wayne and
Sweet Valley, PA 18656
Wyoming
570-477-5717

3150-PM-BWEW0500A
9/2012
- 2 -
PENNSYLVANIA FISH AND BOAT COMMISSION continued
DIVISION OF ENVIRONMENTAL SERVICES
450 Robinson Lane, Bellefonte, PA 16823-9620
814-359-5147
DIVISION OF FISHERIES MANAGEMENT
450 Robinson Lane, Bellefonte PA 16823-9620
814-359-5110
BUREAU OF LAW ENFORCEMENT
Aids to Navigation Coordinator
P.O. Box 67000, Harrisburg, PA 17106
717-705-7861
PENNSYLVANIA HISTORIC AND MUSEUM COMMISSION
BUREAU FOR HISTORIC PRESERVATION
Commonwealth Keystone Building,
400 North Street, 2nd Floor,
Harrisburg, PA 17120-0093
717-783-8946
PENNSYLVANIA DEPARTMENT OF CONSERVATION AND NATURAL RESOURCES
BUREAU OF FORESTRY
ECOLOGICAL SERVICES SECTION
P.O. Box 8552,
Harrisburg, PA 17105-8852
717-787-3444

3150-PM-BWEW0500B
9/2012
- 1 -
EXHIBIT B
U.S. ARMY CORPS OF ENGINEERS DISTRICT OFFICES
AND
DEPARTMENT OF ENVIRONMENTAL PROTECTION REGIONAL OFFICES
U.S. ARMY CORPS OF ENGINEERS DISTRICT OFFICES
Ohio River Basin
Portions of Lake Erie and Genesee
River Basins
Located in PA
Susquehanna River Basin
Delaware River Basin
Pittsburgh District Corps of Engineers
Regulatory Branch
Federal Building, 20
th
Floor
1000 Liberty Avenue
Pittsburgh, PA 15222
Phone:
412-395-7155
Fax: 412-644-4211
Baltimore District Corps of Engineers
Pennsylvania Field
Office
1631 South Atherton Street, Suite 101
State College, PA 16801
Phone:
814-235-0570
Fax: 814-235-0576
Philadelphia District Corps of Engineers
Regulatory Branch
Wanamaker Building
100 Penn Square East
Philadelphia, PA 19107
Phone:
215-656-6725
Phone: 215-656-6729
(to report violations)
Fax: 215-656-6724
DEPARTMENT OF ENVIRONMENTAL PROTECTION REGIONAL OFFICES
General Permit Registrations associated with oil and gas activities -
The General Permit Registration form and other associated documents must be sent to the appropriate DEP Bureau
of Oil and Gas Management, Surfaces Permitting Section, Regional Office listed below.
Bureau of Oil and Gas Management
Surfaces Permitting Section
County Responsibility
Northwest Regional Office
230 Chestnut Street
Butler, Clarion, Crawford, Elk, Erie, Forest, Jefferson,
Meadville, PA 16335
Lawrence, McKean, Mercer, Venango and Warren
(814) 332-6860
Southwest Regional Office
400 Waterfront Drive
Allegheny, Armstrong, Beaver, Cambria, Fayette,
Pittsburgh, PA 15222-4745
Greene, Indiana, Somerset, Washington and
(412) 442-4024
Westmoreland
Eastern Regional Office
208 W. Third Street, Suite 101
Adams, Bedford, Berks, Blair, Bradford, Bucks, Carbon,
Williamsport, PA 17701
Cameron, Centre, Chester, Clearfield, Clinton, Columbia,
(570) 974-2602
Cumberland, Dauphin, Delaware, Franklin, Fulton,
Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon,
Lehigh, Luzerne, Lycoming, Mifflin, Monroe, Montgomery,
Montour, Northampton, Northumberland, Perry,
Philadelphia, Pike, Potter, Schuylkill, Snyder, Sullivan,
Susquehanna, Tioga, Union, Wayne, Wyoming and York

3150-PM-BWEW0500B
9/2012
- 2 -
DEPARTMENT OF ENVIRONMENTAL PROTECTION REGIONAL OFFICES continued
General Permit Registrations not associated with oil and gas activities –
The General Permit Registration form and other associated documents must be sent to the appropriate delegated
County Conservation District (see Exhibit C). This process does not apply to GP-11 or GP-15, which are sent to the
DEP Regional Offices.
If the County Conservation District has not been delegated responsibility under the Chapter 105 program the General
Permit Registration form and other associated documents must be sent to the appropriate DEP Permitting and
Technical Service Section, Regional Office listed below.
Permitting and Technical Services Section
County Responsibility
Northwest Regional Office
230 Chestnut Street
Butler, Clarion, Crawford, Elk, Erie, Forest, Jefferson,
Meadville, PA 16335
Lawrence, McKean, Mercer, Venango and Warren
(814) 332-6984
Southwest Regional Office
400 Waterfront Drive
Allegheny, Armstrong, Beaver, Cambria, Fayette,
Pittsburgh, PA 15222-4745
Greene, Indiana, Somerset, Washington and Westmoreland
(412) 442-4315
Northcentral Regional Office
208 W. Third Street, Suite 101
Bradford, Cameron, Centre, Clearfield, Clinton, Columbia,
Williamsport, PA 17701
Lycoming, Montour, Northumberland, Potter, Snyder,
(570) 327-0529
Sullivan, Tioga and Union
Southcentral Regional Office
909 Elmerton Avenue, Second Floor
Adams, Bedford, Berks, Blair, Cumberland, Dauphin,
Harrisburg, PA 17110
Franklin, Fulton, Huntingdon, Juniata, Lancaster, Lebanon,
(717) 705-4802
Mifflin, Perry and York
Northeast Regional Office
2 Public Square
Carbon, Lackawanna, Lehigh, Luzerne, Monroe,
Wilkes-Barre, PA 18711-0790
Northampton, Pike, Schuylkill, Susquehanna, Wayne
(570) 826-2511
and Wyoming
Southeast Regional Office
2 East Main Street
Bucks, Chester, Delaware, Montgomery and Philadelphia
Norristown, PA 19401
(484) 250-5970

3150-PM-BWEW0510
10/2012
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WATERWAYS ENGINEERING AND WETLANDS
EXHIBIT D
NOTIFICATION TO USE
BDWW-GP-10
ABANDONED MINE RECLAMATION
1.
I/We
,
(owner name(s))
hereby notify the Department of Environmental Protection of our intent to
(description of activity)
at a point
(describe location)
in
,
(municipality) (county)
2.
I/We have attached a LOCATION MAP of the abandoned mine reclamation indicating the site and a
copy of the PNDI form with initialed Search Receipt.
3.
I/We have enclosed duplicate copies of EXHIBIT D, the LOCATION MAP, and PNDI form with initialed
Search Receipt.
4.
I/We certify that copies of this notification were sent this day
(date)
to
, and
.
(municipality)
(County - Commissioner’s Office)
5.
I/We certify that an EROSION AND SEDIMENT CONTROL PLAN for this project will be
submitted for review by the contractor to the
County Conservation
District prior to construction activities. No earthmoving activities will commence without plan approval.
Signed by:
(print name)
(owner address)
(owner signature) (city/state/zip code)
(title, if applicable)
(owner telephone number)
6.
All temporary road crossings of the regulated waters of the Commonwealth in areas unaffected by
mining activities shall be constructed in accordance with the design standards and conditions of General
Permit BDWM-GP-8.
Signed:
ACKNOWLEDGED:
DATE
GP
FOR DEPT. USE ONLY

3150-PM-BWEW0553
Rev. 7/2016
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WATERWAYS ENGINEERING AND WETLANDS
- 1 -
CHAPTER 105 FEE(S) CALCULATION WORKSHEET
Additional information can be found at
25 PA Code §105.13
(relating to regulated activities –information and fees),
the General Permit Registration
(
3150-PM-BWEW0500
), the Joint Permit Application
(
3150-PM-BWEW0036
)
and the Dam Permit Application
(
3140-PM-BWEW0001
)
Federal, State, county or municipal agencies or municipal authorities:
EXEMPT from fees
These entities are exempt from these fees. If the applicant falls into one of these categories, please check the box above and
provide only the first page of this worksheet with the project application or registration.
ALL OTHERS:
1. Please place an “X” in
all authorizations
the box
that apply
next
to theto
project and complete the fee information below those
authorization(s). Projects may require multiple authorizations and fees, further clarification and examples are included below
and at the end of this document.
2. Total each authorization, Section, and Part. Part One is for Water Obstructions and Encroachment authorizations, Part Two is
for Dam Safety authorizations.
3. Please provide this completed worksheet (page 1 and page 2 and/or page 3, as is appropriate to the project) and a check for
the applicable fee(s) with the project application or registration. The check should be made payable
Commonwealth
to the “
of Pennsylvania Clean Water Fund
OR
Conservation District Clean Water Fund
”,
whichever
is
entity.
NOTES:
Per
25 PA Code §105.13(c)(2)(iii)
Disturbance review fees are calculated by individually adding all of the permanent and
temporary impacts to waterways, floodways, floodplains and bodies of water including wetlands to the next highest tenth acre
and multiplying the permanent and temporary impacts by the respective fees and then these amounts are added to the other
applicable fees.
Entities proposing structures or activities to occupy a Submerged Lands of the Commonwealth must obtain a Submerged
Lands License Agreement (SLLA) and pay the appropriate annual charge. The applicant will be contacted if this charge
applies to the project.
Floodway
–The channel of the watercourse and portions of the adjoining floodplains which are reasonably required to carry
and discharge the 100-year frequency flood. Unless otherwise specified, the boundary of the floodway is as indicated on
maps and flood insurance studies provided by FEMA. In an area where no FEMA maps or studies have defined the boundary
of the 100-year frequency floodway, it is assumed, absent evidence to the contrary, that the floodway extends from the stream
to 50 feet from the top of the bank of the stream.
Wetland and Stream Clarification:
1
In many instances, wetlands are located
within the floodplain of a stream.
These
resources for the purposes of calculating
disturbance fees are considered co-located
or overlapping and the area of disturbance
would only be used once.
2
In the case of GP-5, GP-7 and GP-8 fees
are charged per structure per resource
crossing and the following also applies to
the disturbance fees:
?
A crossing of the stream and the
floodplain with wetlands present within
the
floodplain
is
considered
one
resource crossing.
?
When the crossing traverses a stream
and the floodplain and a wetland that is
located outside of the floodplain or a
wetland that extends out beyond the
floodplain, it is considered two resource
crossings.
Wetland
s
Streams
Floodplains

3150-PM-BWEW0553
7/2016
- 2 -
PART ONE: WATER OBSTRUCTIONS AND ENCROACHMENTS
SECTION A. APPLICATION FEES
WATER OBSTRUCTION AND ENCROACHMENT PERMIT
(Joint Permit Application)
Some activities or structures within a project may also qualify for an accumulation of General Permit fees, please mark
the box above indicating an Individual Water Obstruction and Encroachment Permit AND the corresponding fee(s) in
the General Permit section below those. Activities or structures not qualifying for a General Permit fee must include a
disturbance fee.
Administrative Filing Fee
1
.............................................................................
$ 1,750
+
Temporary Disturbance ($400/0.1ac) ........... acres x $4,000 =
$
+
Permanent Disturbance ($800/0.1ac) ........... acres x $8,000 =
$
= $
WO&E FEE subtotal (a)
$
GENERAL PERMIT(S)
(select activity/structure(s) below, see page 4 for “#”) explanation
Some activities or structures within a project requiring an Individual Water Obstruction and Encroachment Permit may
qualify for an accumulation of General Permit fees, please mark the corresponding fee(s) below but not the box above
indicating a General Permit.
GP-1 Fish Habitat Enhancement Structures ...............................................
$ 50
= $
GP-2 Small Docks and Boat Launching Ramps...........................
(#) x
$ 175
= $
GP-3 Bank Rehabilitation, Bank Protection and
Gravel Bar Removal........................................................... (#) x
$ 250
= $
GP-4 Intake and Outfall Structures .............................................. (#) x
$ 200
= $
GP-5 Utility Line Stream Crossings
2
............................
(#) x
(#) x
$ 250
= $
GP-6 Agricultural Crossings and Ramps ..................................... (#) x
$ 50
= $
GP-7 Minor Road Crossings
2
...................................................... (#) x
$ 350
= $
GP-8 Temporary Road Crossings
2
.............................................. (#) x
$ 175
= $
GP-9 Agricultural Activities .........................................................................
$ 50
= $
GP-10 Abandoned Mine Reclamation ..........................................................
$ 500
= $
GP-11 Maintenance, Testing, Repair, Rehabilitation, or
Replacement of Water Obstructions and Encroachments
1
.................
$ 750
+
Temporary Disturbance ($400/0.1ac) ........... acres x $4,000 =
$
+
Permanent Disturbance ($800/0.1ac) ........... acres x $8,000 =
$
= $
GP-15 Private Residential Construction in Wetlands
1
...................................
$ 750
+
Temporary Disturbance ($400/0.1ac) ........... acres x $4,000 =
$
+
Permanent Disturbance ($800/0.1ac) ........... acres x $8,000 =
$
= $
GP(s) FEE subtotal (b)
$
PART ONE: SECTION A.
APPLICATION FEE(S) subtotal (a+b=c)
$
SECTION B. OTHER FEES
Environmental Assessment for Waived Activities (§105.13(c)(2)(iv)) .........................
$ 500
$
Amendment to Water Obstruction and Encroachment Permit
Major Amendment
1
.....................................................................................
$ 500
+
Temporary Disturbance ................................. acres x $4,000 =
$
+
$
Permanent Disturbance................................. acres x $8,000 =
$
= $
Minor Amendment ......................................................................................
$ 250
$
Transfer of Water Obstruction and Encroachment Permit
does not require submission of this form;
see
Application for Transfer of Permit / Submerged Lands License Agreement (3150-PM-BWEW-0016)
PART ONE: SECTION B.
OTHER FEE(S) subtotal (d)
$
PART ONE:
FEE(S) TOTAL (c+d=e)
$
DEP USE ONLY
FEE TOTAL:
Permit / Authorization Number (s):
Correct Amount:
Check #:
Check Amount:
Payable to:

3150-PM-BWEW0553
7/2016
- 3 -
PART TWO: DAM SAFETY (USE ONE FEE SHEET PER DAM)
SECTION A. APPLICATION FEES
DAM PERMIT APPLICATION –NEW DAM
Size A
Hazard 1 $26,500
Hazard 2 $26,500
Hazard 3 $25,500
Hazard 4 $23,500
$
Size B
Hazard 1 $19,000
Hazard 2 $19,000
Hazard 3 $18,500
Hazard 4 $17,000
$
Size C
Hazard 1 $10,500
Hazard 2 $10,500
Hazard 3 $10,000
Hazard 4 $ 8,000
$
STAGED CONSTRUCTION
NO. OF STAGES BEYOND INITIAL STAGE
X APPLICATION FEE
X 0.90 (90%)
$
DAM PERMIT APPLICATION –MODIFICATION OF DAM
Size A
Hazard 1 $18,500
Hazard 2 $18,500
Hazard 3 $18,500
Hazard 4 $18,000
$
Size B
Hazard 1 $12,000
Hazard 2 $12,000
Hazard 3 $12,000
Hazard 4 $11,500
$
Size C
Hazard 1 $ 7,500
Hazard 2 $ 7,500
Hazard 3 $ 7,500
Hazard 4 $ 7,500
$
STAGED CONSTRUCTION
NO. OF STAGES BEYOND INITIAL STAGE
X APPLICATION FEE
X 0.85 (85%)
$
DAM PERMIT APPLICATION –OPERATION & MAINTANANCE OF EXISTING DAM
Size A
Hazard 1 $12,500
Hazard 2 $12,500
Hazard 3 $12,000
Hazard 4 $10,000
$
Size B
Hazard 1 $10,000
Hazard 2 $10,000
Hazard 3 $ 9,500
Hazard 4 $ 8,500
$
Size C
Hazard 1 $ 7,000
Hazard 2 $ 7,000
Hazard 3 $ 6,500
Hazard 4 $ 6,000
$
PART TWO: SECTION A.
APPLICATION FEE(S) subtotal (a)
$
SECTION B. OTHER FEES
Letter of Amendment or Authorization
Major (≥$250,000)
Size A
$14,700
Size B
$ 8,700
Size C
$ 4,400
$
Minor (<$250,000)
Size A
$ 1,300
Size B
$ 1,000
Size C
$
650
$
Major Dam Design Revision
Size A
$ 4,700
Size B
$ 3,200
Size C
$ 1,700
$
Environmental Assessment
Environmental Assessment for Dam Removal (§105.12(a)(16))
$
500
$
Non-Jurisdictional Dams
$
900
$
Letter of Amendment or Authorization
Size A
$ 1,400
Size B
$ 1,000
Size C
$
900
$
Transfer of Dam Permit
No Proof of Financial Responsibility $ 550
Proof of Financial Responsibility $300
$
Annual Registration
Hazard 1 $ 1,500
Hazard 2
$ 1,500
Hazard 3 $
800
$
PART TWO: SECTION B.
OTHER FEE(S) subtotal (b)
$
PART TWO:
FEE(S) TOTAL (a+b=c)
$
DEP USE ONLY
FEE TOTAL:
Permit / Authorization Number (s):
Correct Amount:
Check #:
Check amount:
Payable to:

3150-PM-BWEW0553
7/2016
- 4 -
GP Fee Explanation (#):
GP #
Description
Fee
Fee Explanation (#)
GP-1
Fish Habitat Enhancement Structures
$ 50
Fee is assessed per project not per individual structure.
GP-2
Small Docks and Boat Launching Ramps
$175
Fee is assessed per individual dock or boat ramp. The fee is the
number
of docks and ramps
totaled times the fee.
GP-3
Bank Rehabilitation, Bank Protection and
Gravel Bar Removal
$250
Fee is assessed per project and not individual bank or gravel bar removal
locations.
Only one single and complete project along a continuous
stream reach not exceeding 500 feet measured down centerline of
stream. Additional projects or areas must be separately registered and
the fee would apply to each registration.
GP-4
Intake and Outfall Structures
$200
Fee is assessed per individual intake or outfall structure. The fee is the
total
number of structures
times the fee.
GP-5
2
Utility Line Stream Crossings
2
$250
Fee is assessed per individual utility line or conduit crossing (a wetland
and stream crossing may be separate crossings even if adjacent). The
fee is the total
number of utility lines
times the
number of resource
crossings
times the fee.
GP-6
Agricultural Crossings and Ramps
$ 50
Fee is assessed per individual crossing or ramp structure. The fee is the
total
number of crossings and ramps
times the fee.
GP-7
2
Minor Road Crossings
2
$350
Fee is assessed per individual minor road crossing (a wetland and stream
crossing may be separate crossings even if adjacent). The fee is the total
number of road crossings
times the fee.
GP-8
2
Temporary Road Crossings
2
$175
Fee is assessed per individual temporary road crossing (a wetland and
stream crossing may be separate crossings even if adjacent). The fee is
the total
number of temporary road crossings
times the fee.
GP-9
Agricultural Activities
$ 50
Fee is assessed per project not per individual structure or activity.
Multiple projects can be registered under a single registration and as such
the fee is applied to each project and then totaled.
GP-10
Abandoned Mine Reclamation
$500
Fee is assessed per project not per individual activity. Multiple projects
can be registered under a single registration and as such the fee is
applied to each project and then totaled.
GP-11
1
Maintenance, Testing, Repair,
Rehabilitation, or Replacement of Water
Obstructions and Encroachments
1
$750
Fee is assessed for each registration package (can include multiple
activities or structures)
and is added to the permanent and temporary
disturbance review fees
calculated for each registration package
respectively.
GP-15
1
Private Residential Construction in
Wetlands
1
$750
Fee is assessed for each registration package (can include multiple
activities or structures)
and is added to the permanent and temporary
disturbance review fees
calculated for each registration package
respectively.
Water Obstruction and Encroachment Examples:
1. GP-7 Minor Road Crossing:
Minor road crossing of a stream that qualifies for BDWM GP-07.
GENERAL PERMIT(S)
(select activity/structure(s) below)
Some activities or structures within a project requiring an Individual Water Obstruction and Encroachment Permit may
qualify for an accumulation of General Permit fees, please mark the corresponding fee(s) below but not the box above
indicating a General Permit.
GP-7 Minor Road Crossings............................................................. 1 (#) x
$ 350
= $ 350
GP(s) FEE subtotal (b)
$ 350
2. Joint Permit Application for Individual Water Obstruction Encroachment Permit:
The project proposes to construct an
access road requiring the placement of fill in 0.27 acres of wetlands as part of a residential subdivision.
Administrative Filing Fee ..............................................................................
$ 1,750
+
Temporary Disturbance ($400/0.1ac).................................0.0 acres x $4,000 =
$
0
+
Permanent Disturbance ($800/0.1ac).................................0.3 acres x $8,000 =
$ 2,400
= $ 4,150
WO&E FEE subtotal (a)
$ 4,150

3150-PM-BWEW0553
7/2016
- 5 -
3. Joint Permit Application for Individual Water Obstruction Encroachment Permit:
The project proposes to construct an
access road and utility line through a wetland and stream. The road will require placement of fill in 0.28 acres of wetlands,
placement of a 45 foot long x 36 inch CMP in the stream and placement of fill in the floodway for road approaches to the
culvert (east approach 35 feet wide x 4 feet deep x 50 feet long and west approach 35 feet wide x 2 feet deep x 15 feet).
The utility line is 30 inch diameter steel pipe carrying petroleum products. The utility line will be open trenched through the
wetland with a permanent right of way of 50 feet x 350 feet and an additional construction right of way 25 feet x 350 feet.
The utility line will be open trenched traversing through the entire floodway and stream with a permanent right of way totaling
50 feet x 68 feet (east floodway 50 feet x 50 feet, stream 50 feet x 3 feet and west floodway 50 feet x 15 feet) and an
additional construction right of way 25 feet x 68 feet.
Administrative Filing Fee ..............................................................................
$ 1,750
+
Temporary Disturbance ($400/0.1ac).................................0.3 acres x $4,000 =
$ 1,200
+
Permanent Disturbance ($800/0.1ac).................................0.9 acres x $8,000 =
$ 7,200
= $10,150
WO&E FEE subtotal (a)
$10,150
4. Joint Permit Application for Individual Water Obstruction Encroachment Permit:
The project proposes to construct a
building, two minor road crossings that qualify for BDWM GP-07 and place three separate utility lines through a wetland and
a separate stream that qualify for BDWM GP-05. The building will require placement of fill in 0.17 acres of wetlands.
Administrative Filing Fee ..............................................................................
$ 1,750
+
Temporary Disturbance ($400/0.1ac).................................0.0 acres x $4,000 =
$
0
+
Permanent Disturbance ($800/0.1ac).................................0.2 acres x $8,000 =
$ 1,600
= $ 3,350
WO&E FEE subtotal (a)
$ 3,350
GENERAL PERMIT(S)
(select activity/structure(s) below)
Some activities or structures within a project requiring an Individual Water Obstruction and Encroachment Permit may qualify
for an accumulation of General Permit fees, please mark the corresponding fee(s) below but not the box above indicating a
General Permit.
GP-5 Utility Line Stream Crossings..................................................... 6 (#) x
$ 250
= $ 1,500
GP-7 Minor Road Crossings............................................................... 2 (#) x
$ 350
= $ 700
GP(s) FEE subtotal (b)
$ 2,200
PART ONE: SECTION A. APPLICATION FEE(S) subtotal (a+b=c)
$ 5,550
Resource/Impact Type Permanent Temporary
Road
0.28
0
Utility Const. ROW
0
0.2
Utility Perm. ROW
0.4
0
Road
0.05
0
Utility Const. ROW
0
0.04
Utility Perm. ROW
0.08
0
Totals:
0.81
0.24
Rounded Totals:
0.9
0.3
Impact Calculations and Summary
Wetland
Floodway/Stream
25 foot construction ROW
50 foot ROW and utility line
35 foot wide road

3150-PM-BWEW0553
7/2016
- 6 -
Dam Safety Examples:
5. New Dam Permit Application:
This project proposes to construct a 25-foot high dam that has a maximum storage of
500 acre-feet of water. This dam would be classified as
§105.91.
a size
There is one
category
home and one “C”
roadway within the inundation area downstream of the dam. This dam would have a hazard
All stream
clas
and wetland impacts are covered under the Dam Permit Application. An Environmental Assessment is required as part of
the Dam Permit Application, but a separate fee is not required.
DAM SAFETY APPLICATION FEES
(TO BE FILED WITH DAM SAFETY WITH THE DAM PERMIT APPLICATION)
DAM PERMIT APPLICATION –NEW DAM
Size C
Hazard 1 $10,500
Hazard 2 $10,500
Hazard 3 $10,000
Hazard 4 $8,000
$ 10,500
DAM SAFETY FEE total
$ 10,050
6. Letter of Authorization with Environmental Assessment:
This project proposes to modify a 25-foot high dam that has a
maximum storage of 500 acre-feet of water. This dam
would be classified as§105.91.
a
size
The
c
proposed modification involves buttressing the downstream slope of the dam with soil to improve the stability. The total
project cost will be $100,000. A small wetland area will be impacted near the toe of the buttress. An Environmental
Assessment will be required to assess the impacts to the wetland.
DAM SAFETY FEES
Letter of Amendment or Authorization
Minor (<$250,000)
Size A
$ 1,300
Size B
$ 1,000
Size C
$
650
$ 650
Environmental Assessment
Letter of Amendment or Authorization
Size A
$ 1,400
Size B
$ 1,000
Size C
$
900
$ 900
DAM SAFETY FEE total
$ 1,550
H
PROPOSED DAM
EXISTING DAM
HOUSE
INUNDATION
LIMIT
WETLANDS
EXISTING
IMPOUNDMENT AREA
H
EXISTING DAM
PROPOSED DAM
HOUSE
INUNDATION
LIMIT
PROPOSED
IMPOUNDMENT AREA

3150-PM-BWEW0553
7/2016
- 7 -
7. New Dam Permit Application with Staged Construction and Disturbance Review Fees:
The project proposes to
construct a staged construction, high hazard dam, to be utilized for containing a slurry impoundment. There will also be a
refuse pile constructed adjacent to the slurry impoundment impacting 1000 linear feet of stream, causing a permanent
disturbance to the 3-foot wide stream and 50 feet of floodway on either side of the stream [1000 x (50+3+50)]. A refuse
stockpile will also impact 200 linear feet of stream, causing a permanent disturbance to the 3-foot wide stream and 50 feet of
floodway on either side of the stream [200 x (50+3+50)]. The Dam Safety Application Fee will include the application fee for
the applicable size and hazard classification of the dam. The Dam Safety Application Fee will also include a fee equal to
90% of the original application fee for each stage beyond the initial stage, including any closure stages.
WATER OBSTRUCTION AND ENCROACHMENT FEES
(TO BE FILED WITH DEP REGIONAL OFFICE, COUNTY CONSERVATION OFFICE, OR DISTRICT MINING)
Administrative Filing Fee
$1,750
Temporary Disturbance ($400/0.1ac)
0.0 acres x $4,000 =
Permanent Disturbance ($800/0.1ac)
2.9 acres x $8,000 =
$23,200
WO&E FEE total
$24,950
DAM SAFETY APPLICATION FEES
(TO BE FILED WITH DAM SAFETY WITH THE DAM PERMIT APPLICATION)
DAM PERMIT APPLICATION –NEW DAM
Size A
Hazard 1 $26,500
Hazard 2 $26,500
Hazard 3 $25,500
Hazard 4 $23,500
$ 26,500
STAGED CONSTRUCTION
No. OF STAGES BEYOND INITIAL STAGE 3 X APPLICATION FEE $26,500 X 0.90 (90%)
$ 71,550
DAM SAFETY FEE total
$ 98,050
Resource/Impact Type Permanent Temporary
Refuse Pile
0
0
Stockpile
0
0
Refuse Pile
2.36
0
Stockpile
0.47
0
Totals:
2.83
0
Rounded Totals:
2.9
0
Wetland
Floodway/Stream
Impact Calculations and Summary
CLOSURE STAGE
STAGE 3
STAGE 2
STAGE 1
(INITIAL STAGE)
SLURRY
DAM
STOCKPILE
SLURRY
IMPOUNDMENT
REFUSE PILE
TOTAL AREA IMPOUNDED
BY DAM

3150-PM-BWEW0553
7/2016
- 8 -
Resource/Impact Type Permanent Temporary
Refuse Pile
0
0
Stockpile
0
0
Refuse Pile
0
0
Stockpile
0.47
0
Totals:
0.47
0
Rounded Totals:
0.5
0
Impact Calculations and Summary
Wetland
Floodway/Stream
8. New Dam Permit Application with Staged Construction:
The project proposes to construct a staged construction, high
hazard dam, to be utilized for containing a slurry impoundment and refuse pile. A refuse stockpile will also impact 200 linear
feet of stream, causing a permanent disturbance to the 3-foot wide stream and 50 feet of floodway on either side of the
stream [200 x (50+3+50)]. The Dam Safety Application Fee will include the application fee for the applicable size and hazard
classification of the dam. The Dam Safety Application Fee will also include a fee equal to 90% of the original application fee
for each stage beyond the initial stage, including any closure stages.
WATER OBSTRUCTION AND ENCROACHMENT FEES
(TO BE FILED WITH DEP REGIONAL OFFICE, COUNTY CONSERVATION OFFICE, OR DISTRICT MINING)
Administrative Filing Fee
$1,750
Temporary Disturbance ($400/0.1ac)
0.0 acres x $4,000 =
Permanent Disturbance ($800/0.1ac)
0.5 acres x $8,000 =
$4,000
WO&E FEE total
$5,750
DAM SAFETY APPLICATION FEES
(TO BE FILED WITH DAM SAFETY WITH THE DAM PERMIT APPLICATION)
DAM PERMIT APPLICATION –NEW DAM
Size A
Hazard 1 $26,500
Hazard 2 $26,500
Hazard 3 $25,500
Hazard 4 $23,500
$ 26,500
STAGED CONSTRUCTION
No. OF STAGES BEYOND INITIAL STAGE 3 X APPLICATION FEE $26,500 X 0.90 (90%)
$ 71,550
DAM SAFETY FEE total
$ 98,050
CLOSURE STAGE
STAGE 3
STAGE 2
STAGE 1
(INITIAL STAGE)
SLURRY
DAM
STOCKPILE
REFUSE PILE
SLURRY
IMPOUNDMENT
TOTAL AREA IMPOUNDED BY
DAM

3150-PM-BWEW0051
Rev. 7/2016
COMMONWEALTH OF PENNSYLVANIA
Instructions
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WATERWAYS ENGINEERING AND WETLANDS
- 1 -
INSTRUCTIONS FOR COMPLETING THE PASPGP-5 REPORTING CRITERIA CHECKLIST
Follow the instructions below (pages 1-6) to complete the PASPGP-5 Reporting Criteria Checklist (pages 1-4)
questionnaire. The questionnaire must be completed and provided 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. Only the completed form
(pages 1-4 need to be provided as part of the DEP Chapter 105 application / registration; do not submit the
instructions.
NOTE:
Many of the questions relate to work
associated
with
a
“Single
and
PASPGP-5 Part II for definition of “Single and Complete Pro
SECTION A: ELIGIBILITY DETERMINATION
Question 1:
Answer YES
if the proposed work associated with the Single and Complete Project individually or cumulatively impacts more
than 1.0 acre of waters and/or wetlands, or results in the loss of greater than 1,000 linear feet of stream
channel(s). The 1.0 acre area measurement includes all attendant features, both temporary and permanent, that
are part of the Single and Complete Project, and the calculation is the sum total of all impacts to waters (streams,
rivers, and other watercourses) and/or wetlands.
Question 2:
Answer YES
if any of the proposed work is located waterward of the ordinary high water mark (OHWM) and/or the mean high
water line (MHWL) of the following ineligible waterbodies within Pennsylvania:
a.
The Delaware River, downstream of the U.S. Route 202 Bridge at New Hope, Pennsylvania;
b.
The Schuylkill River downstream of the Fairmount Dam in Philadelphia, Pennsylvania;
c.
All of the Ohio River;
d.
All of the Beaver River;
e.
All of the Little Beaver Creek;
f.
All of the Mahoning River;
g.
All of the Monongahela River;
h.
The Youghiogheny River from its mouth at McKeesport, Pennsylvania to river mile 31.2 at West Newton,
Pennsylvania;
i.
The Allegheny River, from its mouth in Pittsburgh, Pennsylvania to river mile 197.4 at Kinzua Dam, north of
Warren, Pennsylvania;
j.
The Kiskiminetas River from its mouth near Freeport, Pennsylvania to river mile 26.8 at Saltsburg,
Pennsylvania;
k.
Tenmile Creek from its mouth at Millsboro, Pennsylvania to river mile 2.7; and
l.
Lake Erie activities which require submittal of a DEP Chapter 105 Joint Permit Application or Environmental
Assessment to the DEP. For Lake Erie, the OHWM is located at elevation 573.4.
Question 3:
Answer YES
if any portion of the proposed work has 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.
Question 4:
Answer YES
if the proposed work will 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).
*****

3150-PM-BWEW0051
Rev. 7/2016
Instructions
- 2 -
SECTION B: REPORTING ACTIVITY DETERMINATION
Question 1:
Answer YES
if the proposed work associated with the Single and Complete Project, including any attendant features,
permanently or temporarily impacts greater than 0.5 acre of waters of the United States, including jurisdictional
wetlands.
Questions 2a –2d:
Answer YES
for
2a
if your proposed Single and Complete Project permanently impacts greater than 250 linear feet of streams,
rivers, or other watercourses (excluding wetlands).
If YES
for 2a, answer YES for
2b
if the work associated with the Single and Complete Project for stream bank
stabilization, rehabilitation, protection and/or enhancement propose impacts of greater than 500 linear feet for
stream channel(s).
If YES
for 2a, answer YES for
2c
if the Single and Complete Project qualifies for a DEP GP-1 for Fish and Enhancement
Structures.
If YES
for 2a, answer YES for
2d
if your project is covered by a programmatic state water quality certification issued by
DEP that is conditioned upon receiving approval by the Environmental Review Committee.
See PASPGP-5 Non-reporting Activity 20b for further information.
Question 3:
Answer YES
if more than 0.10 acre of shrub-scrub or forested wetland will be permanently converted to emergent wetland.
Question 4:
Answer YES
if the utility line impacts for the Single and Complete Project exceed 500 linear feet.
Question 5:
Answer YES
if the utility line runs parallel to a stream bed that is within a wetland/stream/waterbody complex.
If the application/registration does not include a utility line, answer NO.
Question 6:
Answer YES
if your application/registration is 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 Army Corps of Engineers (Corps) as a Category III/Reporting Activity. Also enter data
associated with the prior authorizations into table, including the type of authorization or permit, permit or
authorization number(s), date(s) of issuance, and permitted impacts (including square feet or linear feet). Types
of authorizations or permits may be abbreviated as Corps Nationwide Permit (NWP), Corps Individual
Permit (IP), or Corps PASPGP (SPGP).
Questions 7a and 7b:
Answer YES
to
7a
if your project is proposed in one of the following 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.
WATERWAYS
COUNTY
Allegheny River (from Kinzua Dam to the Ohio River)
Armstrong, Clarion, Forest, Venango, Warren,
Conewango Creek
Warren
French Creek
Crawford, Erie, Mercer, Venango
Conneaut Outlet
Crawford
Conneautee Creek
Crawford
LeBoeuf Creek
Erie
Muddy Creek
Crawford
Shenango River (Pymatuning Reservoir to Big Bend)
Crawford and Mercer
Delaware River
Monroe, Pike, Wayne
Cussewago Creek
Crawford
Little Mahoning Creek
Indiana
Little Shenango River
Mercer
Oil Creek
Venango
West Branch of French Creek
Erie
Woodcock Creek
Crawford

3150-PM-BWEW0051
Rev. 7/2016
Instructions
- 3 -
Questions 7a and 7b (cont):
If YES
for 7a, answer YES to
7b
if
you
have
received
documented
clearance
determination from the Corps pursuant to Section 7 of the Endangered Species Act dated May 4, 2015 or later.
Documented clearance from the USFWS could include PNDI l
USFWS
letter
the
language
must
indicate
“no
effect”
or
species.”
Questions 8a and 8b:
Answer YES
to
8a
if the proposed work will impact Federally regulated wetlands in one of the below listed counties.
Counties: Adams, Berks, Bucks, Carbon (only Aquashicola Creek Watershed), Chester, Cumberland, Delaware,
Dauphin (only Swatara Creek Watershed), Franklin (only Antietam Creek Watershed) Lancaster, Lebanon,
Lehigh, Monroe, Montgomery, Northampton, Schuylkill (only Swatara Creek Watershed), and York.
If YES
for 8a, answer YES for
8b
if you have received documented
clearance
from
the
USFWS,
determination from the Corps pursuant to Section 7 of the Endangered Species Act dated May 4, 2015 or later.
Documented clearance from the USFWS could include a PNDI l
USFWS
letter
the
language
must
indicate
“no
effect”
or
species.”
Questions 9a and 9b:
Answer YES
for
9a
if your completed PNDI search identifies a potential conflict(s) for a Federally listed species.
If YES
for 9a, answer YES for
9b
if you have received additional documented clearanc
determination from the Corps, or agree through signing the PNDI receipt to comply with the avoidance measures
associated with Federally listed species in completing the proposed work.
Question 10:
Answer YES
if the proposed work is associated with maintenance dredging of a reservoir to maintain the designed storage
capacity, including the removal of accumulated sediments, and the work is authorized pursuant to Section 7 of
the Dam Safety and Encroachments Act, 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)).
For work associated with maintenance of a pond that qualifies for DEP Chapter 105 Waiver 14, enter NO.
Questions 11a –11c:
Answer YES
for
11a
if the DEP Chapter 105 application/registration required you to submit a Cultural Resources Notification
Form to the Pennsylvania Historic and Museum Commission (PHMC), and you have included the response letter
from the State Historic Preservation Office (SHPO), i.e. PHMC.
Cultural Resources Notification Form is not required for DEP Chapter 105 General Permits (GP). If registering
use of a GP, answer YES.
If YES
for 11a, answer YES for
11b
if the SHPO, i.e., PHMC has determined that archaeological or other cultural
resources are believed to exist within the permit area, or has recommended that a Phase 1 archeological survey
be performed.
If PHMC has determined that archaeological or other cultural resources are believed NOT to exist within the
permit area, answer NO.
If YES
for 11b, answer YES for
11c
if you have received documented clearance from PHMC or a No Potential to Effect
determination from the Corps.
Documented clearance from
on Historic Properties”;
ng that “Historic
a letter Properties
stati
(historic a
unlikely to occur within
or a letter stating
the
that noproject
sites that are listed
area”;
or eligible for listing in the
National Register will be effected.
If YES, provide copy of such document(s) in application / registration.
Questions 12a and 12b:
Answer Yes
for
12a
if the proposed work occurs in a component of the National Wild and Scenic River System or in a river
officially designated by
for possible
Congress
inclusion in as
the System
a “Study
(See below for River”
listing of
waters).
1.
Allegheny River, from the Kinzua Dam Mile 197.2, downstream approximately 7 miles to the US Route 6
Bridge, at mile 190.7, in Warren, then from the Buckaloons Recreation Area in Allegheny National Forest at
mile 181.7 downstream 47 miles to Alcorn Island just north of Oil City at river mile 133.7, and then continuing
from the Franklin Wastewater Treatment Plant at mile 122.7, downstream 31 miles to the refinery at
Emlenton mile 90.7;

3150-PM-BWEW0051
Rev. 7/2016
Instructions
- 4 -
Questions 12a and 12b (cont):
2.
Clarion River from mile 91.1 in the Borough of Ridgeway, Elk County, Pennsylvania, at the National Forest
and Gamelands Boundary to mile 39.4 at the normal pool elevation of Piney Dam;
3.
Upper Delaware Scenic and Recreational River, including the ¼ mile buffer from each bank, beginning at
Hancock, New York, and continuing 73.4 river miles to Mill Rift, Pennsylvania;
4.
Middle Delaware Scenic and Recreational River (from bank to bank) as it flows through the Delaware Water
Gap National Recreation Area;
5.
Lower Delaware River beginning 7 river miles north of Belvidere, New Jersey, continuing to Washington
Crossing, Pennsylvania, including Paunnacussing Creek within Solebury Township, all of the Tinicum Creek
including Rapp Creek and Beaver Creek Tributaries, and Tohickon Creek from the mouth to the Lake
Nockamixon Dam, including a ¼ mile buffer from each bank; and
6.
White Clay Creek watershed including all of its tributaries.
If YES
for 12a, answer YES for
12b
if 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.
If YES, provide copy of such document(s) in application / registration.
Question 13:
Answer YES
if the proposed project requires the preparation of an Environmental Impact Statement (EIS).
Question 14:
Answer YES
if the proposed regulated activity or area of indirect impact (secondary impact) extends across state boundaries
(i.e., the work in not wholly located within the Commonwealth of Pennsylvania).
Question 15:
Answer YES
if you are proposing activities 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.
Question 16:
Answer YES
if the proposed work is 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.
Question 17:
Answer YES
if the proposed work will alter, use, build upon, attempt to possess, or potentially harm or impair any existing or
proposed Corps of Engineers Civil Works project, or any Corps of Engineers owned or managed property.
Additional information on the location of Corps Civil Works projects and property may be obtained by checking
with the appropriate Corps District.
Questions 18a –18c:
Answer YES
for
18a
if the proposed project is part of or involves the construction or expansion of a residential, commercial or
institutional subdivision or development.
If YES
for 18a, answer YES for
18b
if greater than 0.25 acre of wetlands exist within the property boundary that are not
being directly impacted as part of this application/registration.
If YES, provide total remaining wetland
acreage.
If YES
for 18a, and 18b, answer YES for
18c
if you proposing to protect the wetland area(s) through a deed restriction
or conservation easement that
Protective
follows
Covenants. the
If YES, attach
Corps’
a copy of
Model
the
proposed deed restriction or conservation easement to this form and submit with your application /
registration form.
Question 19:
Answer YES
if temporary impacts associated with a Single and Complete Project will be in place greater than 1 year.
Also, answer YES if you are requesting an extension of an existing DEP Chapter 105 GP-8 or GP-11
acknowledgement that will result in the temporary impacts now exceeding one year.
Question 20:
Answer YES
if you have any pending applications/registrations with DEP or the Corps that are necessary for your total
proposed project to function and meet its intended purposed.
If YES, provide the following information:
?
Application/registration Number / Type: The application/registration number given by DEP, if known. If
unknown, the application/registration type, enter DEP General Permit, Joint Permit Application, Dam Permit,
Environmental Assessment, etc.

3150-PM-BWEW0051
Rev. 7/2016
Instructions
- 5 -
Question 20 (cont):
?
Project Name: The name the project is commonly referred to
?
Date of Submittal: The date the application/registration was submitted to DEP
?
DEP Reviewing Office:
Name of DEP Regional Office, or County Conservation District reviewing
application/registration.
?
Corps Reviewing Office:
If application/registration is being reviewed by the Corps, enter Baltimore,
Pittsburgh or Philadelphia District.
Question 21:
Answer YES
if you are 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 FE Walter Dam, located in Carbon and Luzerne
County, Pennsylvania between March 15 and June 30.
Questions 22a and 22b:
Answer YES
for
22a
if you are proposing work in the below listed waters.
Waterway
Action Area
(From Point Specified to the
Confluence with the Delaware River)
Latitude
Longitude
Marcus Hook Creek
US Route 13 Bridge
39.822054
-75.409873
Stoney Creek
US Route 13 Bridge
39.828408
-75.400953
Chester Creek
Kerlin Street Bridge
39.855846
-75.37641
Ridley Creek
McDade Boulevard
39.869522
-75.356692
Crum Creek
US Route 13 Bridge
39.866799
-75.340677
Darby Creek
Pine Street Bridge
39.914006
-75.259994
Frankford Creek
Frankford Avenue/US 13 Bridge
40.005314
-75.070173
Frankford Creek (Original Mouth)
End of Channel
40.004912
-75.070173
Pennypack Creek
Route 13 Bridge
40.043421
-75.020638
Poquessing Creek
Mill Road bridge
40.043421
-75.982076
Neshaminy Creek
Rapids just below Hulmeville
Road Bridge (SR 513), Bucks
County
40.141393
-74.911899
Unnamed Tributary 1, located in Croydon, PA
River Road crossing
40.085774
-74.8856
Otter/Mill Creek
US 13 (Bristol Pike) Bridge
40.100424
-74.866976
Unnamed Tributary 2, located in Bristol, PA
Wood Street Bridge
40.102044
-74.845682
Martins Creek
Main Street (Tulleytown)
40.141975
-74.812026
Scott's Creek
End of creek
40.12921
-74.793879
Scott's Creek Relocated Channel, located
at Money Island, Bucks County, PA
First culvert crossing
40.125578
-74.776886
Non-Tidal Tributaries
Buck Creek
Delaware Canal
40.243699
-74.838279
Dyers Creek
Delaware Canal
40.267098
-74.858495
Houghs Creek
Delaware Canal
40.28148
-74.865783
Jericho Creek
Delaware Canal
40.313984
-74.902899
Pidcock Creek
Delaware Canal
40.331508
-74.935788
If YES
for 22a, answer YES for
22b
if you can conduct the work in compliance with the following conservation
measures:
1.
No work shall occur from March 15 to November 15, of any given year.
2.
All Dredging shall be performed by a mechanical dredge and/or techniques (clamshell bucket etc.).
3.
All work, including the installation of turbidity curtains and dewatering cofferdams, shall be performed during
low tide or when the tide is waterward of the proposed work in all tidal waterbodies listed, or during periods
of low or no flow in the non-tidal waterbodies listed.

3150-PM-BWEW0051
Rev. 7/2016
Instructions
- 6 -
Questions 22a and 22b (cont):
4.
Blasting is not authorized by the PASPGP-5 within the listed waterbodies.
5.
Pile Driving:
a.
Piles shall not be greater than 12 inches in diameter;
b.
Piles shall be installed using a vibratory hammer or an impact hammer provided noise attenuation
devices (cushion blocks,
ft etc.)
start”are
is used,
performed
and
each
“so da
start” is the building up of power slowly during pil
leave the area; and
c.
Pile driving activities shall be limited to no more than 12 hours per day.
*****
SECTION C: CERTIFICATION
Please sign and date in the appropriate locations. The submission will not be accepted unless the original form and copy are
signed and dated by the applicant (the owner). (See
Chapter 105 Water Obstructions and Encroachment General Permit
Registration (3150-PM-BWEW0500)
Section A –Applicant Information for clarification on applicant signatures)
*****
IMPERVIOUS SURFACE DATA FOR CORPS
Questions 1a –1c:
Answer YES
for
1a
if your project is located in the area covered by the Corps of Engineers Philadelphia District (Delaware
River Watershed), or Chester, Lancaster, or York County. If YES, answer 1b and 1c.
If YES
for 1a, answer YES for
1b
if your project proposes a permanent impervious surface(s) within the footprint of a
waterbody, including wetlands, and enter the amount of impervious fill within the waterbody on the blank line
following the question. Impervious surfaces are defined as a hard surface area which either prevents or retards
the entry of water into the soil. Common impervious surfaces include roof tops, walkways, patios, driveways,
parking lots or storage areas, concrete or asphalt paving, gravel roads, packed earthen material, and oiled
surfaces. Examples of project fill components constructed as a result of permanent discharges of dredged or fill
material into waters of the United States that are considered to be an impervious surface may include, but are
not limited to: house pads, walkways, patios, driveways, parking lots, storage areas, concrete, asphalt paving,
pre-cast concrete planks or slabs, road crossings, and concrete abutments. For bank stabilization activities, an
impervious surface is only applicable to the concrete lining of waterways and grouted riprap/rock within
jurisdictional waters of the United States that exist above the mean high water (MHW) line in tidal waters or
above the ordinary high water mark (OHWM) in non-tidal waters.
The following list contains examples of project components that are
n
ot considered impervious surface cover:
temporary fills/structures; fill for lawns/parks; mechanized land clearing (tilling, etc.); pavers (specifically
designed to allow water infiltration, i.e. with vegetation holes); boat ramps with loose rock, stone, gravels, and
metal grate panels; and bank stabilization with ungrouted riprap, rock, utilizing bio-engineering techniques (e.g.
willow planting, root wads, large woody debris, etc.); rock filled gabions; and any project feature that is
specifically designed to infiltrate water.
If YES
for 1a, answer YES for
1c
if you will be removing any impervious surfaces as part of your project.
If YES, then
enter the amount of impervious surface being permanently removed as part of project.

- 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
could include PNDI language stating
if in a USFWS letter
“NO
the language
KNOWN
mustIMPACT”;
indicate “no effect” or “the project or activity wil
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
determination from the Corps? Documented clearance from the USFWS could include PNDI language
stating
“NO
KNOWN
IMPACT”;
or,age
if must
in
a indicate
USFWS
letter
“no
project or activity will not affect Federally listed
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
dre
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 the
a System?
“Study
See
Rive
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 Protective
Corps’
Covenant?
Model
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

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