1. JOINT PERMIT APPLICATION INSTRUCTIONS
  2. FOR A
  3. PENNSYLVANIA WATER OBSTRUCTION ANDENCROACHMENT PERMIT APPLICATION
  4. AND A
  5. U.S. ARMY CORPS OF ENGINEERSSECTION 404 PERMIT APPLICATION
    1. INTRODUCTION
    2. INTRODUCTION
    3. APPLICATION MAILING INSTRUCTIONS
      1. I. ACTIVITIES WHICH REQUIRE A PERMIT
      2. I. ACTIVITIES WHICH REQUIRE A PERMIT
      3. I. ACTIVITIES WHICH REQUIRE A PERMIT
      4. II. WHICH TYPE OF PERMIT TO APPLY FOR
      5. II. WHICH TYPE OF PERMIT TO APPLY FOR
      6. III. COMPLETING THE JOINT PERMIT APPLICATION FORM
      7. III. COMPLETING THE JOINT PERMIT APPLICATION FORM
      8. III. COMPLETING THE JOINT PERMIT APPLICATION FORM
      9. III. COMPLETING THE JOINT PERMIT APPLICATION FORM
      10. III. COMPLETING THE JOINT PERMIT APPLICATION FORM
      11. III. COMPLETING THE JOINT PERMIT APPLICATION FORM
      12. III. COMPLETING THE JOINT PERMIT APPLICATION FORM
      13. III. COMPLETING THE JOINT PERMIT APPLICATION FORM
      14. III. COMPLETING THE JOINT PERMIT APPLICATION FORM
      15. III. COMPLETING THE JOINT PERMIT APPLICATION FORM
      16. III. COMPLETING THE JOINT PERMIT APPLICATION FORM
      17. III. COMPLETING THE JOINT PERMIT APPLICATION FORM
      18. III. COMPLETING THE JOINT PERMIT APPLICATION FORM
      19. APPENDIX IPERMIT WAIVERS
      20. APPENDIX IPERMIT WAIVERS
      21. APPENDIX IPERMIT WAIVERS
      22. APPENDIX IIGENERAL PERMITS
      23. APPENDIX IIGENERAL PERMITS
      24. APPENDIX III
      25. OUTLINE FOR SUGGESTED HYDROLOGY AND HYDRAULICS REPORT FORM
      26. APPENDIX IV
      27. SAMPLE - REQUIREMENTS FOR A PROPOSED BRIDGE
      28. APPENDIX IV
      29. SAMPLE - REQUIREMENTS FOR A PROPOSED BRIDGE
      30. APPENDIX IV
      31. SAMPLE - REQUIREMENTS FOR A PROPOSED BRIDGE
      32. APPENDIX V
      33. LETTER FROM APPLICANT TO MUNICIPALITY AND COUNTY
      34. TO SATISFY ACTS 14, 67, 68 and 127
      35. GENERAL INFORMATION FORM -- AUTHORIZATION APPLICATION
      36. INSTRUCTIONS
      37. GENERAL INFORMATION
      38. DEFINITIONS
      39. CLIENT INFORMATION
      40. SITE INFORMATION
      41. FACILITY INFORMATION
      42. PROJECT INFORMATION
      43. LAND USE INFORMATION
      44. COORDINATION INFORMATION
      45. CERTIFICATION
      46. APPLICANT’S CHECKLIST
      47. TYPE CODES
      48. CLIENT INFORMATION. Client Type / Codes
      49. SITE INFORMATION. Site-to-Client Relationship Codes
      50. DEP OFFICES
      51. REGIONAL OFFICES
      52. CENTRAL OFFICES
      53. DISTRICT MINING OFFICES
      54. GENERAL INFORMATION FORM – AUTHORIZATION APPLICATION
      55. CLIENT INFORMATION
      56. SITE INFORMATION
      57. FACILITY INFORMATION
      58. PROJECT INFORMATION
      59. LAND USE INFORMATION
      60. COORDINATION INFORMATION
      61. CERTIFICATION
      62. GENERAL INFORMATION FORM -- AUTHORIZATION APPLICATION
      63. APPLICANT’S CHECKLIST
      64. REQUIREMENTS
      65. GENERAL INFORMATION FORM -- AUTHORIZATION APPLICATION
      66. LOCATIONAL DATA CODES
      67. GENERAL INFORMATION
      68. LOCATIONAL DATA CODES
      69. APPENDIX A
      70. AUTHORIZATION/APPLICATION TYPES AFFECTED BY DEP’S LAND USE POLICY
      71. AIR QUALITY PROGRAM
      72. Authorization/Permit Type & Description
      73. (Applies only to air quality permit applications that are outside of an existing
      74. permitted area)
      75. eFACTS Codes
      76. COAL MINING PROGRAM
      77. Authorization/Permit Type & Description eFACTS Codes
      78. INDUSTRIAL MINERALS (NONCOAL) MINING PROGRAM
      79. Authorization/Permit Type & Description eFACTS Codes
      80. OIL & GAS MANAGEMENT PROGRAM
      81. Authorization/Permit Type & Description eFACTS Codes
      82. WASTE MANAGEMENT – HAZARDOUS WASTE PROGRAM
      83. Authorization/Permit Type & Description eFACTS Codes
      84. WASTE MANAGEMENT – MUNICIPAL WASTE PROGRAM
      85. Authorization/Permit Type & Description eFACTS Codes
      86. WASTE MANAGEMENT – RESIDUAL WASTE PROGRAM
      87. Authorization/Permit Type & Description eFACTS Codes
      88. WASTE MANAGEMENT – STORAGE TANKS PROGRAM
      89. Authorization/Permit Type & Description
      90. area)
      91. Authorization/Permit Type & Description eFACTS Codes
      92. RADIATION PROTECTION PROGRAM
      93. Authorization/Permit Type & Description eFACTS Codes
      94. WATER MANAGEMENT – DAM SAFETY PROGRAM
      95. Authorization/Permit Type & Description eFACTS Codes
      96. WATER MANAGEMENT – NPDES PROGRAM
      97. Authorization/Permit Type & Description eFACTS Codes
      98. WATER MANAGEMENT – STATE WATER POLLUTION CONTROL PROGRAM
      99. Authorization/Permit Type & Description eFACTS Codes
      100. WATER SUPPLY MANAGEMENT – SAFE DRINKING WATER PROGRAM
      101. Authorization/Permit Type & Description eFACTS Codes
      102. WATERSHED MANAGEMENT – EROSION & SEDIMENT PROGRAM
      103. Authorization/Permit Type & Description eFACTS Codes
      104. Authorization/Permit Type & Description eFACTS Codes
    4. CHAPTER 105 FEE(S) CALCULATION WORKSHEET
    5. PART ONE: WATER OBSTRUCTIONS AND ENCROACHMENTS
      1. SECTION A. APPLICATION FEES
      2. SECTION B. OTHER FEES
    6. 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. PHMC’S TIME FRAMES
    7. CULTURAL RESOURCE NOTICE
      1. Read the instructions before completing this form.
    8. CULTURAL RESOURCE NOTICE
      1. INSTRUCTIONS FOR COMPLETING THE PASPGP-5 REPORTING CRITERIA CHECKLIST
      2. PASPGP-5 REPORTING CRITERIA CHECKLIST
    9. Request for a Bog Turtle Habitat Evaluation (Phase 1 Survey)
      1. SPECIAL BOG TURTLE HABITAT SCREENING
    10. BOG TURTLE HABITAT - SKETCH PLAN
    11. ENVIRONMENTAL ASSESSMENT FORM (E.A. FORM)
    12. INSTRUCTIONS
    13. Instructions
      1. MODULE S1: PROJECT SUMMARY
      2. MODULE S2: RESOURCE IDENTIFICATION AND CHARACTERIZATION
      3. MODULE S4: MITIGATION PLAN
      4. CERTIFICATION AND FEE
    14. APPENDIX I
    15. APPENDIX IIREGIONAL OFFICES
    16. APPENDIX II
    17. REGIONAL OFFICES continued
    18. APPENDIX III
    19. U.S. ARMY CORPS OF ENGINEERS DISTRICT OFFICES
    20. Appendix IV
    21. Subfacility Codes and Descriptions
      1. Subfacility
      2. Location of
      3. Lat/Long PointCode Name
    22. Appendix VSubfacility Details
      1. Subfacility
      2. Authorized Activities/Structures
      3. Code Name
      4. Subfacility Authorized Activities/StructuresCode Name
      5. Subfacility
      6. Authorized Activities/Structures
      7. Code Name
      8. Subfacility
      9. Authorized Activities/Structures
      10. Code Name
      11. Field Name and Description
      12. Subfacility
      13. Authorized Activities/Structures
      14. Code Name
      15. Field Name and Description
      16. Field Name and Description
      17. Subfacility
      18. Authorized Activities/Structures
      19. Code Name
      20. Field Name and Description
      21. Subfacility
      22. Authorized Activities/Structures
      23. Code Name
      24. Field Name and Description
      25. Field Name and Description
      26. Subfacility
      27. Authorized Activities/Structures
      28. Code Name
      29. Subfacility
      30. Authorized Activities/Structures
      31. Code Name
      32. Field Name and Description
      33. Field Name and Description
      34. Subfacility
      35. Authorized Activities/Structures
      36. Code Name
      37. Field Name and Description
      38. Subfacility
      39. Authorized Activities/Structures
      40. Code Name
      41. Field Name and Description
      42. Subfacility
      43. Authorized Activities/Structures
      44. Code Name
      45. Field Name and Description
      46. CHAPTER 105 ENVIRONMENTAL ASSESSMENT FORM

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Instructions
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
JOINT PERMIT APPLICATION INSTRUCTIONS

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FOR A

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PENNSYLVANIA WATER OBSTRUCTION AND
ENCROACHMENT PERMIT APPLICATION

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AND A

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U.S. ARMY CORPS OF ENGINEERS
SECTION 404 PERMIT APPLICATION
For more information,
visit DEP's website at
www.dep.gov
US Army Corps
of Engineers

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Instructions
JOINT PERMIT APPLICATION INSTRUCTIONS
TABLE OF CONTENTS
SECTION
TITLE
PAGE #
INTRODUCTION ................................................................................................................. i
APPLICATION MAILING INSTRUCTIONS ......................................................................... iii - iv
I.
ACTIVITIES WHICH REQUIRE A PERMIT
A.
GENERAL
........................................................................................................... 1
B.
PERMIT WAIVERS .................................................................................................. 1
C.
GENERAL PERMITS ............................................................................................... 1- 2
D.
LIMITED POWER PERMITS.................................................................................... 3
E.
ENVIRONMENTAL ASSESSMENT FORM (E.A. FORM) ....................................... 3
II.
WHICH TYPE OF PERMIT TO APPLY FOR
A.
GENERAL
........................................................................................................... 4
B.
SMALL PROJECTS.................................................................................................. 4 - 5
III.
COMPLETING THE JOINT PERMIT APPLICATION
SECTION A - APPLICATION TYPE .................................................................................. 6
SECTION B - APPLICANT IDENTIFIER............................................................................ 6
SECTION C - PROJECT LOCATION DATA AND STATUS.............................................. 6
SECTION D - AQUATIC RESOURCE IMPACT TABLE .................................................... 6 - 8
SECTION E - COMPLIANCE REVIEW.............................................................................. 8
SECTION F - APPLICATION COMPLETENESS CHECKLIST......................................... 8 - 16
SECTION G - DETERMINATION OF APPLICATION FEES ............................................. 17
SECTION H - ADJOINING PROPERTY OWNERS........................................................... 17
SECTION I - CERTIFICATION AND SIGNATURE .......................................................... 17 - 18
APPENDICES
I.
PERMIT WAIVERS
II.
GENERAL PERMITS
III.
OUTLINE FOR SUGGESTED HYDROLOGY AND HYDRAULICS REPORT FORM
IV.
SAMPLE - REQUIREMENTS FOR A PROPOSED BRIDGE
V.
LETTER FROM APPLICANT TO MUNICIPALITY AND COUNTY TO SATISFY
ACTS 14, 67, 68 AND 127

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Instructions
INTRODUCTION
i
This booklet is intended to assist the applicant in properly completing a
Joint Permit Application
for a state
(Department of Environmental Protection (DEP))
Water Obstruction and Encroachment permit
and a
federal (U.S. Army Corps of Engineers (the Corps))
Section 9, Section 10 or Section 404
permit. DEP is
committed to the explanation of its permitting requirements and in assisting, to the fullest extent possible, those
persons whose activities require them to secure a state and/or federal permit.
The basic procedure for making application involves submitting three (3) complete application packages
including the General Information Form and Environmental Assessment Form to the appropriate DEP Regional
Office indicated on the
Application Mailing Instructions (page iii).
One copy of the application will be
retained by the Department, one will be forwarded to the Corps, and the third copy will be forwarded to the
Pennsylvania Fish and Boat Commission.
Upon favorable review of the complete application package, the applicant may receive both state and federal
permits for the project.
The following items explain some of the review procedures associated with the application process.
Pre-Application Conferences
The purpose of a pre-application conference is to improve communications between the potential applicant and
the Department staff that will be reviewing any future permit application. Although this requires an investment
of time, it is the Department’s
mproved
goal
applications
that
beingthese
submitted byconf
applicants. Likewise, DEP staff is afforded the opportunity to learn details about the project prior to reviewing
the application.
Pre-application conferences are not required, but are available for anyone requesting a meeting. DEP does
recommend the pre-application meeting for all first time applicants and for complex and technically difficult
projects. DEP staff will review all of the application forms and documentation required to be completed by the
applicant. They will also inform the applicant of any fees, reports or license agreements which may be
required.
PASPGP
The PASPGP (Pennsylvania State Programmatic General Permit) authorizes the discharge of dredged,
excavated or fill material or structures into waters of the United States and waters of the Commonwealth with
1(one) acre or less of proposed impact, including wetlands. The PASPGP is a federal Clean Water Act
Section 404 Permit issued for the Commonwealth of Pennsylvania for processing approximately 80 percent of
the applications received. If appropriate, DEP will provide both state and federal authorizations for the
proposed project.
There is no additional initial work on the part of the applicant to initiate the PASPGP review process. All permit
applications submitted to the Department will be reviewed to determine the scope of the work and the
applicability of the PASPGP. If it is determined that the application does not qualify for this dual (state and
federal) review by DEP, the application will be forwarded to the Corps for a separate federal review. All other
applications will be processed entirely by DEP. In either case, the applicant will be advised as to which
procedure his application is undergoing.

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INTRODUCTION
ii
State Water Quality Certification
A separate issue associated with the permit application process is the need for the applicant to obtain a State
Water Quality Certification as required under Section 401 of the Federal Water Pollution Control Act
(33 U.S.C.A. 1341(a)). There is no need on the part of the applicant to initiate this review; it is initiated by the
Department for each application that is submitted. If DEP approves an application and issues a Water
Obstruction and Encroachment Permit, the review for the State Water Quality Certification will have been
completed and the State Water Quality Certification will be included with the permit.
DEP Permit Review Process and Permit Decision Guarantee
This policy (021-2100-001) establishes a standardized review process and processing times for all Department
permits. For the permits contained in the Permit Decision Guarantee, the Department guarantees to provide
permit decisions within the published timeframes, provided applicants submit complete, technically adequate
applications that address all applicable regulatory and statutory requirements in the first submission. Staff will
follow a Department-wide standard process for receiving, prioritizing, accepting, reviewing, denying, and
approving applications for permits or other authorizations.
The time frame established for completing an application for the 105 program is 93 business days. The
applicant can assist the Department in meeting this goal by providing a complete application package.
Therefore, it is important that the instructions contained in this booklet be followed very closely. Errors,
omissions and other irregularities in the application package must be resolved before any detailed reviews of
an application may begin.
Submerged Lands License Agreement
A Submerged Lands License Agreement (SLLA)
will be required for any regulated water obstruction or
encroachment to occupy submerged lands of this Commonwealth located in a navigable lake or river or stream
declared a Public Highway. No separate action or application for such agreements is required by the
applicant. Upon review of all applications for a
Water Obstruction and Encroachment permit
, DEP will
determine if a SLLA is required. If one is required, it will be prepared and sent to the applicant for signature.
Growing Smarter Legislation
On June 22, 2000, Governor Tom Ridge signed into law "Growing Smarter" initiatives by amending the
Municipalities Planning Code (MPC) with the new laws - Acts 67, 68 and 127. The new law also provides state
agencies additional legal authority to consider local zoning ordinances and comprehensive plans in making
certain permit and funding decisions.
To fulfill its obligation under these new laws, the Department of Environmental Protection (DEP) will take into
consideration local land use plans and ordinances when reviewing permit applications.

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Instructions
iii
APPLICATION MAILING INSTRUCTIONS
The set of three (3) completed copies of the application, the General Information Form (GIF) and the
Environmental Assessment Form (E.A.) with all other required documents, should be mailed or hand delivered
to the appropriate DEP Regional Office.
PLEASE KEEP THIS SHEET FOR ANY FUTURE
CORRESPONDENCE OR TELEPHONE CONTACTS WITH THE REGIONAL OFFICE.
DEPARTMENT OF ENVIRONMENTAL PROTECTION REGIONAL OFFICES
Joint Permit Applications associated with oil and gas activities –
The Joint Permit Application and other associated documents must be sent to the appropriate DEP Bureau of
District Oil and Gas Operations office listed below.
Bureau of District Oil and Gas Operations
County Responsibility
Northwest District
Northwest Regional Office
Butler, Clarion, Crawford, Elk, Erie, Forest, Jefferson,
230 Chestnut Street
Lawrence, McKean, Mercer, Venango and Warren
Meadville, PA 16335
(814) 332-6860
Southwest District
Southwest Regional Office
Allegheny, Armstrong, Beaver, Cambria, Fayette, Greene,
400 Waterfront Drive
Indiana, Somerset, Washington and Westmoreland
Pittsburgh, PA 15222-4745
(412) 442-4024
Eastern District
Northcentral Regional Office
Adams, Bedford, Berks, Blair, Bradford, Bucks, Carbon,
208 W. Third Street, Suite 101
Cameron, Centre, Chester, Clearfield, Clinton, Columbia,
Williamsport, PA 17701
Cumberland, Dauphin, Delaware, Franklin, Fulton,
(570) 321-6550
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

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iv
Joint Permit Applications not associated with oil and gas activities –
The Joint Permit Application and other associated documents must be sent to the appropriate DEP
Waterways and Wetlands Program office listed below.
Waterways and Wetlands Program
County Responsibility
Northwest Regional Office
Butler, Clarion, Crawford, Elk, Erie, Forest, Jefferson,
230 Chestnut Street
Lawrence, McKean, Mercer, Venango and Warren
Meadville, PA 16335
(814) 332-6984
Northcentral Regional Office
Bradford, Cameron, Centre, Clearfield, Clinton, Columbia,
208 W. Third Street, Suite 101
Lycoming, Montour, Northumberland, Potter, Snyder,
Williamsport, PA 17701
Sullivan, Tioga and Union
(570) 327-3574
Northeast Regional Office
Carbon, Lackawanna, Lehigh, Luzerne, Monroe,
2 Public Square
Northampton, Pike, Schuylkill, Susquehanna, Wayne and
Wilkes-Barre, PA 18711-0790
Wyoming
(570) 826-2511
Southwest Regional Office
Allegheny, Armstrong, Beaver, Cambria, Fayette, Greene,
400 Waterfront Drive
Indiana, Somerset, Washington and Westmoreland
Pittsburgh, PA 15222-4745
(412) 442-4000
Southcentral Regional Office
Adams, Bedford, Berks, Blair, Cumberland, Dauphin,
909 Elmerton Avenue, Second Floor
Franklin, Fulton, Huntingdon, Juniata, Lancaster, Lebanon,
Harrisburg, PA 17110
Mifflin, Perry and York
(717) 705-4802
Southeast Regional Office
Bucks, Chester, Delaware, Montgomery and
2 East Main Street
Philadelphia
Norristown, PA 19401
(484) 250-5970

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Instructions
I. ACTIVITIES WHICH REQUIRE A PERMIT
- 1 -
A.
GENERAL:
A Chapter 105 Water Obstruction and Encroachment permit is needed for any structure or
activity which changes, expands or diminishes the course, current or cross section of a
watercourse,
floodway
or
body of water
.
Figure 1.1
shows a cross sectional view of a typical watercourse (stream,
creek, river, etc.) and adjoining floodway. 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).
Floodways (to carry the 100-year frequency flood) are determined in one of two ways.
Many
municipalities have flood insurance studies and maps prepared by the Federal Emergency Management
Agency (FEMA) which indicate floodway boundaries. Inquiries to the local municipal government will
disclose whether the floodway has been determined along a particular watercourse or body of water. In
the absence of any FEMA determined floodway along a watercourse, the floodway shall be considered to
extend 50 feet landward from the top of each streambank (refer to
Figure 1.1
).
Bodies of water include both natural and artificial lakes, ponds, reservoirs, swamps, marshes and
wetlands. In a few locations, FEMA has delineated a floodway along a body of water. However, in most
cases, no FEMA floodway has been delineated and the 50-foot rule does not apply. A permit is required
only if the structure or activity adjoins or encroaches into the body of water or into the floodway as
defined by FEMA.
Under
the Department’s
106 Rules and Regulations
Chapter
additional permit requirements are placed
upon the Commonwealth, political subdivisions of the Commonwealth and Public Utilities for activities,
structures or an assembly of materials on the
floodplain
which may impede, retard or change flood
flows. The difference between floodway and floodplain is illustrated in Figure 1.2. Since such activities
and structures within the floodway portion of the overall floodplain are already regulated under the
Chapter 105 Rules and Regulations, the Chapter 106 requirements are basically limited to that floodway
fringe area shown in
Figure 1.2
.
The same
Joint Permit Application
shall be used for both
Chapter’s
105 and 106
Water Obstruction and Encroachment permits
.
B.
PERMIT WAIVERS:
Before preparing a joint permit application, the applicant should review the
availability of permit waivers for specified structures and activities. These waivers are listed under
Section 105.12 of
DEP’s
105 RulesChapter
and Regulations and have been included in Appendix I of
this section. Most of the waivers are automatic and do not need prior DEP approval. Any person using
such waivers needs only to develop and retain such information as will verify their qualification to use a
waiver. This information would be made available to DEP only if so requested as a result of a general
inquiry or in the investigation of a complaint. The only exceptions to the "automatic" waivers concern
subsections 105.12(a)(4), 105.12(a)(11), 105.12(a)(16) and 105.12(b)(2). These subsections require that
any person wishing to use these permit waivers must first submit specified information to DEP for its
review and approval. The fee required for a project authorized under these permit waivers shall be
consistent with 25 PA Code §105.13 (relating to regulated activities – information and fees).
See
§105.13(c)(2)(iv) for additional information.
C.
GENERAL PERMITS:
Certain regulated structures and activities may qualify for permitting under one of
12 available Department General Permits. Specific limits and restrictions on use are contained in the
instructions for each General Permit. Applicants need only to register their intent to construct the project
in accordance with conditions of the general permit. Contact the appropriate DEP Regional Office
(page iii) (for more information, visit us through the Pennsylvania homepage at www.state.pa.us or visit
DEP directly at
www.dep.pa.gov
) for copies of the General Permits. A list and brief description of the
available General Permits are included in Appendix II of this section. The fee required for a project
authorized under these general permits shall be consistent with 25 PA Code §105.13 (relating to
regulated activities – information and fees).
See §105.13(c)(2)(ii) for additional information.

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I. ACTIVITIES WHICH REQUIRE A PERMIT
- 2 -
DISTANCE FROM TOP OF BANK TO LIMIT OF FLOODWAY AS DETERMINED
BY FEMA FLOOD INSURANCE STUDY. IF NO FEMA STUDY HAS BEEN COMPLETED,
THIS DISTANCE WILL BE 50 FEET.

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Instructions
I. ACTIVITIES WHICH REQUIRE A PERMIT
- 3 -
D.
LIMITED POWER PERMITS:
These permits are required by the Limited Power Act of June 14, 1923,
P.L. 704, (as amended by the Act of July 19, 1935, P.L. 1363) for all power projects consisting of
complete units of improvements or development for the supply of water power or for the procuring or
supply of light, heat or power, by electricity, consisting of changes in streams to develop water power or
to supply water for stream power. When, upon review of a Joint Permit Application, it is determined that
a Limited Power Permit is required, DEP will forward a separate
Limited Power Permit application
(3100-PM-WE0003)
to the applicant.
E.
ENVIRONMENTAL ASSESSMENT FORM (E.A. FORM):
The Pennsylvania Department of
Environmental Protection requires a review of all environmental impacts associated with activities (see
EA Instructions 3150-PM-BWEW0017 and EA Form 3150-PM-BWEW0017A) or structures in
watercourses, floodways, and/or bodies of water, including wetlands.
If you are seeking a Water
Obstruction and Encroachment Permit to "build in" reservoirs, lakes, ponds, swamps, wetlands, marshes,
bogs, floodways, waterways, or open waters in Pennsylvania, an Environmental Assessment must be
approved by the DEP as part of the permit review process.
The Environmental Assessment is a
necessary part of a complete Chapter 105 Dam Safety and/or Water Obstruction and
Encroachment Permit application.
If you are completing the Environmental Assessment as part of a
permit application, several maps, plans and other information requested herein will have already been
submitted via the application package and do not have to be duplicated. In these instances, please
reference where in the application the information is provided. However, these documents must be
included with the Environmental Assessment if a permit is not required.
IN THE FOLLOWING
CIRCUMSTANCES, A CHAPTER 105 PERMIT IS NOT NECESSARY BUT AN APPROVED
ENVIRONMENTAL ASSESSMENT IS REQUIRED:
§105.12(a)(11)
-
Waiver No. 11 removal of abandoned dams, water obstructions and
encroachments.
§105.12(a)(16)
-
Waiver No. 16 restoration activities associated within an approved
DEP Restoration Plan.
§105.15(b)
-
For structures or activities where water quality certification is
required under Section 401 of the Clean Water Act (33 U.S.
CA. §1341). These activities include but are not limited to Federal
Nationwide Permits (NWP).
§105.15(a)(2) and (3)
-
Non-jurisdictional dams that are located in wetlands or exceptional
value water as defined in Chapter 93.
The fee required for a project authorized under these permit waivers (when a Chapter 105 permit is not
necessary) shall be consistent with 25 PA Code §105.13 (relating to regulated activities –information and
fees). See §105.13(c)(2)(iv) for additional information.
The Environmental Assessment for all Chapter 105 General Permits has been deemed approved by the
Department. Therefore, the Environmental Assessment is not necessary when registering for use of a
General Permit.
For further information regarding Environmental Assessments, please contact the Waterways and
Wetland Program in the appropriate DEP Regional Offices listed on page iii (Application Mailing
Instructions).

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Instructions
II. WHICH TYPE OF PERMIT TO APPLY FOR
- 4 -
A.
GENERAL:
If you do not qualify for a waiver or general permit, the Department’
105 Rules and
Regulations allow for two types (Small Projects and Standard) of joint permit application to be made for a
Water Obstruction and Encroachment Permit. A
Small Projects Application
may be made for projects
in streams and floodplains where insignificant impacts on safety and protection of life, health, property
and the environment can be demonstrated without detailed studies or engineering calculations. For all
other projects including those projects affecting wetlands and those projects where safety and
environmental impacts must be determined through technical studies, a
Standard Application
must be
made. Either type of application can be made using the
Joint Permit Application forms
. The applicant
shall indicate which type of application is being made at the beginning of the forms and then follow
subsequent instructions to complete the application type indicated. 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). See §105.13(c)(2) for additional information.
B.
SMALL PROJECTS:
Small Projects are those water obstructions and encroachments located in a
stream or floodplain which will have an "insignificant impact" (see definition below) on safety and
protection of life, health, property and the environment as defined in Chapter 105.1 of the Dep
regulations.
The Small Projects Application may not be used for projects located in wetlands
.
Examples of small projects include, but are not limited to:
Bridges; culverts; streamside retaining walls; boat and other access ramps; docks; on-grade
construction and excavations within the floodplain; low flow crossings; removal of flood debris;
removal of limited amounts of unvegetated gravel bars; small buildings and similar structures
within the floodplain; repair, reconstruction, widening, extension and replacement of existing
water obstructions; and water pollution treatment devices.
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). See §105.13(c)(2)(i) for additional information.
INSIGNIFICANT IMPACTS:
Generally speaking, the size and scope of a small project must not
represent an obvious resultant increase in local flood heights or patterns because the activity is small
compared to the overall channel and/or floodplain size. In other cases, a project may appear to cause a
localized increase in flood stages but such increases will be across open or unimproved land owned or
placed under flowage easement by the applicant. The absence of any buildings or other structures in
floodplain areas adjacent to the proposed project also helps to justify a small project. Similar criteria
would apply to judging potential environmental impacts.
SPECIFIC LIMITING CRITERIA FOR SMALL
PROJECTS APPLICATIONS INCLUDE:
1.
No work in wetlands.
2.
No impacts to a Federal wilderness area or national historic site.
3.
No impacts on the habitat of rare, threatened or endangered species or species of special
concern based on a review of the PA Natural Diversity Inventory (the PNDI form is contained in
the application package).
4.
No significant impacts to public water supplies, high quality and exceptional value watersheds,
scenic rivers, and wild and stocked trout streams.
5.
Low flow culvert crossings and bridges must be constructed in accordance with the
specifications and to the general configurations shown in SAMPLE DRAWINGS A1 AND A2.
Fill placed for approach roadways must be minimal.
6.
Except for low flow crossings, all new bridges and culverts should have a single waterway
opening equal to or greater in width than the existing channel in the area of construction.

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7.
Channel excavation projects associated with existing bridges or culverts are generally limited to
50 feet above and below the structure.
8.
Channel restoration work is generally limited to a total length of 200 feet to repair recent flood
damages. Unvegetated gravel bars may be removed down to 6 inches above the water level at
the time of construction. Channels may not be realigned except to restore pre-flood alignments.
Construction equipment shall not be used in the stream channel unless absolutely necessary.
9.
The cross sectional area of buildings or other structures placed in the floodplain must be
insignificant compared to the overall size of the floodplain. The final grade of excavations,
regradings, parking lots and similar work in the floodplain shall, on average, match the existing
land surface grade. For structures, a letter is required from the local municipality indicating
consistency with their local floodplain management program.
10.
Sinkhole repairs in a watercourse must not use any materials regulated by the Solid Waste Act.
NOTES:
(1)
MAXIMUM HEIGHT OF STRUCTURES AND FILL PLACED IN THE CHANNEL MAY NOT EXCEED
[ .6 x D (AVG. CHANNEL DEPTH) ]
(2)
SEE MANUFACTURERS’
SPECIFICATIONS FOR SPACING AND OVERTOPPING FILL REQUIREMENTS
SAMPLE DRAWING A1: LOW FLOW CROSSING
NOTE:
THIS SAMPLE DRAWING SHOWS A PROPOSED BRIDGE THAT DOES NOT INVOLVE PLACING ABUTMENTS OR PIERS WITHIN
THE CHANNEL, IT HAS AN UNDERCLEARANCE THAT DOES NOT EXTEND BELOW THE LOWEST NATURAL STREAMBANK
ELEVATION, AND THE PROJECT DOES NOT INVOLVE PLACING SUBSTANTIAL FILL TO BUILD UP THE APPROACHES.
THEREFORE, STRUCTURE DIMENSIONS AND CONSTRUCTION MEET GUIDELINES CRITERIA.
SAMPLE DRAWING A2: TYPICAL BRIDGE CROSSING

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SECTION A - APPLICATION TYPE:
Place an "X" in either the STANDARD or SMALL PROJECTS
block to indicate type of application being made.
SECTION B - APPLICANT IDENTIFIER: Applicant Name:
Please fill in the requested information
about the applicant (the owner) as accurately as possible. If privately owned, please list all owners. If
owned by a partnership, please list all members. If owned by a corporation, a political subdivision, or a
Commonwealth department, board, commission, receiver, trustee or authority, please list the name of the
entity.
SECTION C - PROJECT LOCATION DATA AND STATUS:
• Provide the USGS name of the stream, river
ed”.
or
If bod
wetla
enter "wetland". Provide the Chapter 93 Water Quality Standards designation (25 Pa. Code § 93).
• Place an "X" in the appropriate Corps District block. Baltimore District covers the Susquehanna River
Basin; Philadelphia District covers the Delaware River Basin; Pittsburgh District covers the Ohio River
basin, and portions of the Lake Erie and the Genessee River Basins located in Pennsylvania.
• Provide the name of the USGS 7 1/2 minute Quadrangle map where the project is located and
provide the other site location information as requested. Each application must contain a project
location map drawn to, or otherwise utilizing an existing 1:24000 scale (1 inch equals 2,000 feet).
This is the scale used on U.S.G.S. 7.5 minute topographic maps. (A current list of USGS Map
Dealers in Pennsylvania is available on the internet at www.usgs.gov).
A photocopy of the
appropriate U.S.G.S. topographic map, with the project site identified, is the recommended method to
comply with this requirement). The photocopy must include a 3-inch radius of map coverage around
the project site.
If a U.S.G.S. photocopy is used for a location map, all the requirements of
Subsection 105.13(d)(1)(ii) of DEP’s regulations
required
will be
location map features if another type, or hand drawn map is used.
• Provide a concise and accurate narrative of the project type, purpose and need.
• Place an "X" in the appropriate box if any portion of the proposed project has been authorized. If yes,
provide the date authorized. Please attach a detailed description of those portions of the project that
have been authorized.
SECTION D - AQUATIC RESOURCE IMPACT TABLE:
Please prepare and provide a detailed worksheet of the waters and/or wetlands impacts associated with
the project work site as requested in Section E, Item 8; include the unique identifier, project/site name,
date and applicant name/client, project information (including latitude and longitude) and waters and/or
wetlands impact data in table format. Provide one row of data for each regulated (DEP Chapter 105 and
Corps Section 404) structure or activity and type of impact for the proposed project based on the
instructions for each requirement below; all dimensions should be reported to the nearest one (1) foot,
rounding up.
Please place an “X” in the appropriate box to indi
Table indicate that all items are included or indicate and list those items which were not included.
Depending on the details of project, not all impact types will be included in the table.
Project Information:
?
Structure / Activity Unique Identifier for each regulated structure and/or activity being
proposed
?
Aquatic Resource being impacting; stream or wetland

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?
Aquatic Resource Type; based on wetland or stream
o
Stream type: perennial, intermittent, ephemeral stream or floodway
o
Wetland type: PEM, PSS, PFO or POW wetland
?
Latitude (dd nad 83)
?
Longitude (dd nad 83)
?
Work proposed / impact type: aerial, boring, excavation or fill
?
Waters Name: name of the stream or wetland (if available)
?
PA Code Chapter 93 Designation:
Army Corps of Engineers / Section 404 jurisdictional area:
?
Corps Impact Type: temporary, permanent or n/a;
Permanent Impacts –For the purpose of the PASPGP-5, permanent impacts are
defined as waters of the United States, including jurisdictional wetlands indefinitely
filled, flooded, excavated, or drained as a result of the regulated activity. Permanent
impacts may or may not be considered a loss of waters of the United States, as
defined above, since some permanent impacts, such as those associated with bank
stabilization and stream/wetland enhancement projects, may not have a permanent
adverse effect.
Temporary Impacts –For the purpose of the PASPGP-5, temporary impacts are
defined as waters of the United States, including jurisdictional wetlands not filled,
flooded, excavated, or drained for an indefinite period of time, and restored to pre-
construction contours and elevation.
?
"n/a" if no proposed work in, over, or under waters and/or wetlands
?
Stream Impact: width, length and area of stream impact;
o
Width: top of bank to top of bank, of transverse and/or full channel fill stream impacts;
o
Length: down the center line of stream, of transverse and/or full channel fill stream
impacts;
o
Area: direct and indirect/secondary stream impact; dewatering or fill placed in stream
channel;
?
"n/a" if impact is to a wetland OR if "n/a" to Corps Impact Type
?
Wetland Impact: area of impacts to wetlands; indicate "n/a" if impact is to a stream OR if
"n/a" to Corps Impact Type
DEP / Chapter 105 jurisdictional area:
?
PADEP Impact Type: temporary or permanent.
Permanent Impacts are those areas affected by a water obstruction or encroachment
that consist of both direct and indirect impacts that result from the placement or
construction of a water obstruction or encroachment and include areas necessary for
the operation and maintenance of the water obstruction or encroachment located in,
along or across, or projecting into a watercourse, floodway or body of water.
Temporary Impacts are those areas affected during the construction of a water
obstruction or encroachment that consists of both direct and indirect impacts located
in, along or across, or projecting into a watercourse, floodway or body of water that are
restored upon completion of construction. This does not include areas that will be
maintained as a result of the operation and maintenance of the water obstruction or

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III. COMPLETING THE JOINT PERMIT APPLICATION FORM
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encroachment located in, along or across, or projecting into a watercourse, floodway
or body of water (these are considered permanent impacts).
?
Floodway Impact:
direct and indirect/secondary 100-year floodway impact, including
watercourse;
?
Wetland Impact: Provide the square feet area of impacts to wetlands; indicate "n/a" if impact
is to a stream
Provide completed aquatic resource impact table with Chapter 105 Water Obstruction and Encroachment
application/registration. The
Aquatic Resources Impact Table (3150-PM-BWEW0557)
worksheet or
equivalent may be used to complete this requirement.
SECTION E - COMPLIANCE REVIEW:
Place an "X" in either the YES or NO block to indicate if
applicant (owner and/or operator) are currently in violation of any permits issued by the Department. If
YES –complete the necessary information for questions 1 –3. Use additional sheets of paper, if
required, and attach to application.
SECTION F - APPLICATION COMPLETENESS CHECKLIST:
Applicant must place an entry - Y = Yes,
N = No, N/A = Not Applicable - for each requirement in the column designated as Applicant Entry. If you
are applying under the
Small Projects Application
format, place an entry in only those spaces prefixed
by an asterisk (*).
The Department’s
review
of
all
applications
begins
application package is incomplete, the Department will correspond with the applicant and request
submission of corrected and/or previously omitted documents. The Department’s
93 business day goal
for review and decision of permit applications will not begin until a complete application has been
received.
See Section 105.13
of
the 105
DEP’s
Rules andChapter
Regulations for specific
requirements. Additional guidance for the required checklist items is as follows:
CHECKLIST ITEMS:
a.
General Information Form (GIF):
Complete and attach to each copy of the application package,
the "PERMIT APPLICATION - GENERAL INFORMATION" form.
Additional instructions for
completing this form are provided at the front of the application package.
Permit application
properly signed, sealed and witnessed:
See detailed instructions contained in
Section I
of the
permit application.
b.
Application Fee enclosed (see Section G):
Please attach the check made payable to
"Commonwealth of Pennsylvania Clean Water Fund"
to the front of the application package.
c.
Copies and proof of receipt - Acts 14/67/68/127 notification:
Act 14 Municipal and County
Notification requires that the Department wait 30 days from the date of project notification to both
the local and county governments before issuing its permit(s). DEP must receive a copy of the
Act 14 notification letters to each affected municipality and
proof
that each municipality received
the notification.
DEP is specifically inviting the local municipality and the county to submit
comments to DEP related to comprehensive plans and zoning ordinances under Acts 67 and 68.
Act 14 notices must be amended to include specific language as outlined on the sample notification
letter (see Appendix VII).
d.
Cultural Resource Notice:
Complete and attach to each copy of the application package,
completed form "Cultural Resource Notice" for the determination of historic/archaeological sites.

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Also attach a copy of the return receipt and, when applicable, the PHMC review letter. Additional
instructions for completing this notice is provided with the form.
e.
Pennsylvania State Programmatic General Permit -5 (PASPGP-5) Reporting Criteria
Checklist:
Complete
and
attach
to
each
copy
of
the
-5
appl
Reporting Criteria Checklist”(3150-PM-BWEW0051) to determine the appropriate PASPGP-5
review procedure. Additional instructions for completing this screening are included on the form.
f.
Bog Turtle Habitat Screening:
Bog Turtle Habitat screening is required for permit applications
which may impact wetlands in the following counties: Adams, Berks, Bucks, Carbon (Aquashicola
Creek Watershed only), Chester, Cumberland, Dauphin (Swatara Creek Watershed Only),
Delaware, Franklin (Antietam Creek Watershed Only), Lancaster, Lebanon, Lehigh, Monroe,
Montgomery, Northampton, Schuylkill (Swatara Creek Watershed only) and York. Complete and
attach to each copy of the application package, the “Request for a Bog Turtl
(3150-PM-BWEW0550) and a copy of either a “No Effect”
determination
Engineers or a copy of documented clearance from the US Fish and Wildlife Service.
g.
Pennsylvania Natural Diversity Inventory (PNDI) Search:
Coordination with the Pennsylvania
Natural Heritage Program (PNHP) regarding the presence of Federal threatened and endangered
(T&E) species and State T&E species or species of special concern on the project site is a
regulatory requirement for this permit application/registration. Early coordination (prior to
submission) with the appropriate jurisdictional agencies using the PA Conservation Explorer,
previously known as the Pennsylvania Natural Diversity Inventory (PNDI) Environmental Review
Tool (PNDI ER Tool), is the most effective means of timely permit decisions. The PA Conservation
Explorer can be accessed at the
www.naturalheritage.state.pa.us/
website. First time users will
have to register at the website before conducting the review. Upon completion of the review, a
PNDI Receipt, valid for a period of two years from the date the search was conducted, is
automatically available for printing. To provide proof of coordination with PNHP and PNDI,
applicants must submit a PNDI Receipt as part of the permit application/registration.
PNDI reviews can still be obtained free-of-charge for users without access to a computer using the
standard process of requesting a project review directly from each jurisdictional agency—PA
Department of Conservation and Natural Resources (DCNR), PA Game Commission (PGC), PA
Fish and Boat Commission (PFBC) and the U.S. Fish and Wildlife Service (US FWS) instead of
generating a PNDI Receipt instantly through the PA Conservation Explorer. The standard PNDI
review process user is responsible for securing PNDI Receipts from each jurisdictional agency—
DCNR, PGC, PFBC and the U.S. FWS.
?
PNDI Receipts from each jurisdictional agency will be included with the application/registration
package. The PNDI review is not complete or satisfied unless PNDI Receipts are included from
all four jurisdictional agencies listed above. Applicants are encouraged to use the PA
Conservation Explorer because using this tool is the most effective means of a timely permit
decision.
If the review determines there are potential impacts to a T&E species or species of special concern,
the PNDI Receipt will provide an explanation of the potential impact(s) and instructions on how to
resolve the potential impact(s).
READ AND FOLLOW THESE INSTRUCTIONS CAREFULLY.
Following the procedure outlined by the Department of Environmental Protection (DEP) in the
Policy for Pennsylvania Natural Diversity Inventory (PNDI) Coordination During Permit Review and
Evaluation
, No. 021-0200-001
(PNDI Policy)
will allow applicants to meet regulatory requirements.

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III. COMPLETING THE JOINT PERMIT APPLICATION FORM
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There are two options available to applicants for handling PNDI coordination in conjunction with
DEP’s Permit Review Process: sequential review an
Sequential Review:
?
The applicant runs the PNDI search and completes all coordination with the appropriate
jurisdictional agencies prior to submitting the permit application/registration. The applicant
will include with the application/registration a signed PNDI Receipt, and clearance letter(s)
from the jurisdictional agency(ies) if the PNDI Receipt shows a Potential Impact.
?
If selecting sequential review, different items are required to be included as part of the
permit application/registration package based on the search results:
o
If
the
PNDI
Receipt
shows
“No
Known
Impact
PNDI Receipt.
o
If the PNDI Receipt contains “Avoidance Measures”, the
satisfied unless the applicant has signed where required on the PNDI Receipt, indicating
he/she can and will fulfill the Avoidance Measure(s) for that project. DEP recommends
including Avoidance Measures in the Project Description. Please provide a copy of the
PNDI Receipt signed as explained above and in the certification section.
?
If the applicant cannot or chooses not to meet the Avoidance Measure(s), he/she
must follow the same process for PNDI Receipts showing “Poten
below.
?
If
the PNDI
Receipt
shows "Potential Impact”
that the applicant provides additional information, outlined in the PNDI Receipt, to the
agencies noted on the receipt for further review. Please provide a copy of the signed PNDI
Receipt
showing
“Potential
Impact”
AND
the
Receipt along with proof of delivery to the appropriate jurisdictional agency(ies) where
further coordination is required. If this coordination is not complete prior to submitting the
permit application/registration package; the application/registration will be subject to the
concurrent review process as outlined below.
Concurrent Review:
?
The applicant runs the PNDI search and will engage in consultation with the applicable
jurisdictional agency(ies). DEP will allow technical review of the permit to occur concurrently
with the T&E species or species of special concern consultation with the jurisdictional
agency(ies)
?
If selecting a concurrent review, the applicant will include with the permit
application/registration a signed PNDI Receipt processed through the PA Conservation
Explorer
OR
PNDI receipts from each jurisdictional agency if the standard process of
requesting a project review was used.
o
It is important to note, however, that the concurrent review option carries certain risks
and consequences to the applicant, including:
?
The permit may not be issued/acknowledged until each potential impact is resolved.
See
DEP’s
Permit Review Process and Permit Decision Guarantee Policy,
Document No. 021-2100-001
(PRP/PDG Policy)
?
The proposed activity subject to the permit application/registration may need to be
redesigned as a result of the PNDI consultation
(
PNDI Policy
pages 7-8).
Note: Any

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III. COMPLETING THE JOINT PERMIT APPLICATION FORM
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substantive project or design changes to the application will require a new
application and fee to be submitted.
h.
Plans:
The applicant must prepare a site plan, cross-sectional drawings and any other drawings as
needed to clearly illustrate, in graphic form, the specific construction details and potential hydraulic
impacts of the proposed project. These plans must be submitted on size 8 ½" x 11" paper or on
larger sized paper provided each sheet is individually folded to 8 ½" x 11" size. Any plans received
in rolls or that have not been folded to the proper size will be discarded and will be sufficient cause
to consider the application incomplete. All drawings shall contain a title block at the lower right
corner of the sheet. The title block shall contain the project name, name of the applicant, name of
the plan PREPARER (if different then the applicant) and the date the plan was prepared.
(1)
Site Plan:
A site plan must be included in the application which provides a complete plan
view of the proposed structure or activity and those adjoining upstream and downstream
areas where potential and/or actual hydraulic or environmental impacts will occur (see Sample
Site Plans). Specific requirements are as follows:
(a)
Plans shall clearly show existing and proposed limits for all regulated waters of this
Commonwealth (edges of streams, rivers, lakes, swamps, bogs, marshes, wetlands,
ponds or reservoirs) and the limits of their floodplains. When the proposed worksite is
located within a detailed Federal Emergency Management Agency (FEMA) flood
insurance study area, the existing and proposed FEMA 100-year frequency
floodway
limits must be shown on the site plan. When the project involves impacts to wetlands,
the
wetland
boundaries
must
be
delineated
Wetland Delineation Policy (see Environmental Assessment Form).
(b)
Plans must be drawn to a scale of 1 inch equals 200 feet or larger and show all
proposed structures or activities and all existing roads, utility lines, lots (show property
lines and names of adjoining property owners), buildings and other man-made structures
in the area of the proposed project. Natural features such as contours, surface drainage
patterns and other prominent topographic features should be illustrated. A north arrow
must be placed on the site plan.
(c)
When
required
under
subsection
105.13(i)
o
must be affixed with a registered profession
(2)
Cross Sectional Drawings:
A cross sectional drawing of existing and proposed conditions at
the project site must be included on the site plan or on a separate plan (see Sample Plans in
Appendix IV). If the proposed project causes changes in upstream or downstream flood water
surface elevations, cross sectional drawings are required for the channel and floodway
conditions in these areas.
All cross sections must show existing and proposed design
discharge water surface elevations and the 100-year frequency flood water surface elevation.
(3)
Profiles:
Certain regulated activities require that a plan profile drawing be prepared. Profiles
require that the streambed, normal water surface and flood water surfaces be plotted (see
Figure III-2). This requirement is listed under (and must be completed for) the following
subsections:
105.151 - Culverts and Bridges
105.191 - Stream Enclosures
105.231 - Channel Changes and Dredging
105.261 - Fills, Levees, Floodwalls and Streambank Retaining Devices

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i.
Location map:
Provide an 8 ½" x 11" copy of a 7.5 minute U.S.G.S. quad map with map name.
j.
Project description narrative:
Provide a detailed description of the project including proposed
impacts to waters and/or wetlands, structure type(s), amounts of excavation/fill and what purpose
the activity will serve. For example:
The project will consist of placing a 48-inch CM pipe
culvert in Pine Creek with 2 feet of rock fill overtop to provide vehicle access to our new
home. There is no other existing access to this site.
The narrative must also describe in detail
what effects the project will have on public health, safety and the environment. The narrative must
contain a statement on why the project must be built in, along, across or over a watercourse,
floodway or body of water. Is there an alternative to the proposed project that would not require
such impacts?
If the PNDI Project Environmental Review Receipt for the project contains Avoidance Measures,
please include the Avoidance Measures in the description.
Please prepare and provide a detailed chart of each proposed impact to waters and/or wetlands as
it
pertains
to
the
project’s
structions provided in
activities
Section D. Include a per
unique the
identifier (
i.e. Stream 1, Wetland 3, etc
) which will be used in all related items. The
Aquatic
Resource Impact Table (3150-PM-BWEW0557)
worksheet or equivalent which provides all of the
details requested must be attached as part of the Registration package.
k.
Color photographs with map showing location taken:
Provide color photographs of the
proposed site that accurately depict the project area and areas of proposed impact. In addition,
provide a relative scale of the project to the surrounding area and a map showing the location and
orientation of each photograph. The number of photographs needed to meet this requirement will
vary with the size and/or length of proposed work. For singular or small worksites such as a bridge
project, two photographs taken at the site, one looking upstream and one looking downstream, may
be all that is required if the adjoining channel reaches and overbank areas are not obscured by
trees, brush or similar visual impediments. In such cases, additional photos will be needed looking
upstream and downstream to the bridge site. Also, more photos may be required in overbank areas
to show the relative location, elevation and condition of nearby buildings and the area that the
bridge approach roadways will occupy. For extensive projects such as channel realignment or
restoration projects, photos looking upstream and downstream should be taken at regular intervals
along the proposed workreach. Again, the interval of these photo reference sites will be dictated by
the degree of visual impediments existing along the proposed workreach.
Three sets of color photographs (one set for each permit application package) are required and
they should be mounted in transparent photo holders or glued/taped to a 8 ½" x 11" piece of
cardboard. The photo reference number, in ink, should be placed on the lower left corner of each
photo along with the date the photo was taken. To the photograph sheet(s) attach a copy of the
general site plan and mark the site of each photo (number) on the map (See Sample Photo
Reference Map in Appendix III). From the photo site, draw a short arrow in the direction that the
photo was taken.
l.
Environmental Assessment form:
An incomplete Environmental Assessment form will result in
the entire application being considered
INCOMPLETE
. Please refer to "Environmental Assessment
Form (E.A. Form) Instructions."

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III. COMPLETING THE JOINT PERMIT APPLICATION FORM
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STOP IF YOU ARE APPLYING FOR A SMALL PROJECTS PERMIT. YOU HAVE COMPLETED ALL THE
NECESSARY REQUIREMENTS FOR ATTACHMENTS TO THE APPLICATION PACKAGE UPON
REACHING SECTION F, ITEM l. GO TO SECTION G AND COMPLETE THE REST OF THE APPLICATION.
IF YOU ARE APPLYING FOR A STANDARD PERMIT, CONTINUE ON TO COMPLETE SECTION F,
ITEMS m. THROUGH t. AND THEN THE REST OF THE APPLICATION.
m.
Erosion and Sediment Control Plan and approval letter:
Attach copies of a letter of plan
approval from the appropriate county conservation district and copies of the actual Erosion and
Sediment Control Plan that was approved.
n.
Hydrologic and hydraulic analysis:
This analysis should be prepared as a separate report and
contain the seal and certification statement of the licensed Professional Engineer who prepared the
report, when appropriate. The following is a
suggested
format to be used in the preparation of a
HYDROLOGY AND HYDRAULICS
(H & H) Report. Under each section title, a discussion is
presented on what information is required and where to secure that information.
(1) SITE HISTORY AND CONDITIONS:
List all historical flood data that can be secured for this
site or structure including existing conditions and problems. Typical items to be addressed
include:
(a)
Flood records. This can be flood records secured from nearby U.S.G.S. gaging stations,
municipal flood records or eyewitness accounts by area residents. Flood events must
be presented as either a discharge rate, such as cubic feet/second or as a high water
mark indexed to local elevations or referenced to a point on a local permanent structure.
All flood events must be dated. If known, list past flood damages to homes or other
structures in the project area.
(b)
Site Conditions. State what flooding problems exist at this site (if any) that will be
corrected by the proposed project. Note any adverse influences on site conditions
caused by nearby structures such as bridges, culverts, fills, etc.
(2) HYDROLOGY:
The objective of this part of the report is to list, or show the calculations
performed to determine the design and 100-year frequency flood discharges for the proposed
worksite. If the site is located within the limits of a detailed Federal Emergency Management
Agency (FEMA) flood insurance study, contact the local municipality to find the 100-year and
other frequency flood discharges.
No other listed or computed flood discharges will be
accepted for sites located within a FEMA detailed flood study area.
In the absence of any flood records, studies or other published flood records, the design and
100-year frequency flood discharges must be determined through the use of currently accepted
methods for determining rainfall and runoff amounts.
(a)
RAINFALL DETERMINATIONS - The Department recommends use of the following
to determine rainfall amounts or intensities.
(i)
Rainfall Duration Frequency Tables for Pennsylvania
- This DEP publication
may be obtained by sending a request to:
DEP - Bureau of Watershed Management
Division of Water Use Planning
10th Floor, Rachel Carson State Office Building
P.O. Box 8555
Harrisburg, PA 17105-8555

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(ii)
SCS TR-55, Urban Hydrology for Small Watersheds
- Copies of -55SCS’
may be obtained by contacting:
National Technical Information Service
5301 Shawnee Road
Alexandria, VA 22312
Telephone (703) 605-6585
http://www.ntis.gov/
Publication Number: NTIS # PB87-101580/AS
(iii) Weather Bureau Technical Paper 40, U.S. Department of Commerce,
Hershfield, D.M.
- This publication is no longer in print although past copies are
still in wide use by engineering consultants. It is the basis for the rainfall maps
included
in
TR-55.
It
is
available
as
a
pdf
document
here:
http://www.nws.noaa.gov/oh/hdsc/PF_documents/TechnicalPaper_No40.pdf
(b)
RUNOFF CALCULATIONS - The Department recommends the use of the following
methods to determine design and 100-year frequency flood discharges:
(i)
Rational:
This method is widely discussed and explained in engineering/hydrology
texts. We recommend reference to the discussion and use of the worksheets
contained
in
the
Erosion
Department’s
and Sediment Pollution Control
Program Manual.
This manual can be obtained by contacting:
DEP - Bureau of Waterways Engineering and Wetlands
Division of Waterways, Wetlands and Training
2nd Floor, Rachel Carson State Office Building
P.O. Box 8460
Harrisburg, PA 17105-8460
Telephone (717) 787-8568
(ii)
SCS TR-55, Urban Hydrology for Small Watersheds:
See previous reference
under Rainfall Determinations, Part ii. for where to obtain copies.
(iii) Procedure PSU-IV for Estimating Design Flood Peaks on Ungaged
Pennsylvania Watersheds (manual and computerized versions).
(iv) Other Methods and Computer Models:
The use of other hydrology methods
including computer programs will be accepted on a case by case basis. All
submissions must be clear and adequately illustrated with factors, coefficients and
other components clearly referenced.
Input data and results from computer
models must be summarized or listed for review.
NOTE:
Usual practice is to use two separate methods to compute and compare site
hydrology.
(3) HYDRAULIC ANALYSIS:
This part of the report must clearly demonstrate the difference in
hydraulic capacity, stability and flood water surface elevations between existing and proposed
conditions. For example, if the proposed project is to consist of enlarging a 500-foot reach of
channel for flood control, the capacity of both the existing channel section and proposed
channel section must be computed. This will also produce flow velocities from which channel
stability may be reviewed. Finally, the design and 100-year frequency flood water surface
elevations may be plotted. The amount of increase in flood water surface elevations allowed

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under the Chapter 105 Rules and Regulations varies with the type of structure/activity and its
location.
The Department recommends the following computational methods or programs be used for
hydraulic analysis:
(a)
Mannings Equation - Used to determine the capacity of, and flow velocity within, open
channel
sections.
Refer
to
the
Department
Program Manual for details on how to use Mannings Equation.
(b)
Hydraulic Design of Highway Culverts, HDS No. 5, U.S. Department of Transportation,
FHA. This publication is used to determine the capacity of, and water surface elevations
for flow through culverts and some small bridges. There is also a computer version titled
HY-8. This publication may be obtained by contacting:
National Technical Information Service
5301 Shawnee Road
Alexandria, VA 22312
Telephone (703) 605-6585
http://www.ntis.gov/
Publication Number: NTIS # PB86-196961/AS
(c)
HEC-2 Water Surface Profiles, U.S. Army Corps of Engineers. This is a computer
program used for backwater analysis of existing and proposed channel conditions. This,
or a similarly detailed backwater analysis, is required to establish the changes (if any) in
flood water surface elevations caused by the proposed project. This program may be
obtained through the Corps or from various commercial software retailers.
(d)
HEC-RAS River Analysis System. This is a computer program which allows the user to
perform one-dimensional steady flow, unsteady flow, and sediment transport calculations.
Information on this program can be obtained from:
U.S. Army Corps of Engineers
Hydrologic Engineering Center
609 Second Street
Davis, CA 95616
Telephone (530) 756-1104
The Chapter 105 Rules and Regulations contain specific permit application information
requirements (in addition to those in Section 105.13) and design, construction, operational
and/or maintenance approval criteria under the following Subchapters:
Subchapter C. Culverts and Bridges
Subchapter D. Stream Enclosures
Subchapter E. Channel Changes and Dredging for Facility Construction and
Maintenance
Subchapter F. Fills, Levees, Floodwalls and Streambank Retaining Devices
Subchapter G. Stream Crossings, Outfalls and Headwalls
Subchapter H. Docks, Wharves and Bulkheads
Subchapter I. Commercial Dredging
Subchapter J. Discharges of Dredged or Fill Material

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The applicant must demonstrate in the H & H report that all appropriate Subchapter
requirements have been met. An outline for a suggested Hydrology and Hydraulics Report is
listed in Appendix V.
o.
Stormwater
Management
Analysis
w/consistency letter:
Water
obstructions
and
encroachments requiring DEP permits are often additionally regulated under local municipal
stormwater control ordinances adopted under the Stormwater Management Act (32 P.S.
§§ 680.1-680.17).
If such an ordinance exists, an an
Stormwater Management Plan must be undertaken and reviewed by the local municipality. The
analysis and a letter of review from the municipality must be included in the application package.
p.
Floodplain Management Analysis w/consistency letter:
If the proposed water obstruction or
encroachment is located within a floodway delineated on a FEMA
impact on the floodway delineation and water surface profiles may be required. The analysis and a
letter of review from the municipality must be included in the application package.
q.
Risk Assessment:
If the stormwater and/or the floodplain management analysis conducted under
items l or m indicate increases in peak runoff rates or flood elevations, include as a separate
document, a description of property and land uses which may be affected and an analysis of the
degree of increased risk to life, property and the environment.
r.
Professional
engineer’s
seal
If the proposed
and
water
certification
obstruction or
encroachment poses a threat to human life or substantial potential risk to property, the plans,
specifications and reports accompanying such applications shall be affixed with the seal of a
registered professional engineer and a certification, signed by the registered professional engineer,
which shall read as follows:
"I (name) do hereby certify pursuant to the penalties of 18 Pa.
C.S.A., Section 4904 to the best of my knowledge, information
and
belief,
that
the
information
contained
in
the
accompanying plans, specifications and reports has been
prepared in accordance with accepted engineering practice,
is true and correct, and is in conformance with Chapter 105 of
the rules and regulations of the Department of Environmental
Protection."
s.
Alternatives Analysis:
As a separate document, an analysis must be performed detailing
practicable alternatives to the proposed activities, including alternative locations, routings, designs,
etc., to avoid or minimize adverse environmental impacts.
t.
Mitigation plan:
The mitigation plan must be a separate document which describes how project
planning employed mitigation concepts
105 Rules and Regulations.
as defined
If
these impacts cannot be eliminated, then the mitigation plan must include details and plans for
replacing the impacted environment. The specific replacement resources or environments must be
itemized and construction, operation and maintenance activities must be detailed in the plan. As
defined under Section 105.1 of DEP’s
105 RulesChapter
and Regulations,
Mitigation
is:
(i)
An action undertaken to accomplish one or more of the following:
(A) Avoid and minimize impacts by limiting the degree or magnitude of the action and
its implementation.
(B) Rectify the impact by repairing, rehabilitating or restoring the impacted
environment.

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(C) Reduce or eliminate the impact over time by preservation and maintenance
operations during the life of the action.
(ii)
If the impact cannot be eliminated by following clauses (A)-(C), compensate for the
impact by replacing the environment impacted by the project or by providing substitute
resources or environments.
SECTION G - DETERMINATION OF APPLICATION FEES:
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)
which includes
examples. Please provide the completed worksheet and a check for the applicable fee(s) made payable
to the “Commonwealth of Pennsylvania Clean Water Fu
To determine the acreages for permanent and temporary impacts for establishing the disturbance fees in
the fee calculation worksheet referenced above, the following definitions should be used:
Permanent Impacts are those areas affected by a water obstruction or encroachment that consist of
both direct and indirect impacts that result from the placement or construction of a water obstruction
or encroachment and include areas necessary for the operation and maintenance of the water
obstruction or encroachment located in, along or across, or projecting into a watercourse, floodway
or body of water.
Temporary Impacts are those areas affected during the construction of a water obstruction
or encroachment that consists of both direct and indirect impacts located in, along or across,
or projecting into a watercourse, floodway or body of water that are restored upon
completion of construction. This does not include areas that will be maintained as a result of
the operation and maintenance of the water obstruction or encroachment located in, along
or across, or projecting into a watercourse, floodway or body of water (these are considered
permanent impacts).
Examples and clarifying language are provided in the fee calculation worksheet. The acreages
determined for establishing disturbance fees may not be the same acreages that are used for the
purposes of compensatory mitigation.
Reference should also be made to the definition for Small Projects. Per §105.13(c)(2)(i) Small Projects
require a Joint Application for a Water Obstruction and Encroachment Permit and therefore will follow the
same fee requirements.
The determination of application fees is for the DEP permit only. Upon receipt of a copy of the
application package, the U.S. Army Corps of Engineers will determine if any federal permit application
fees apply. If fees are required, the applicant will be so advised.
SECTION H - ADJOINING PROPERTY OWNERS:
List the name and address of all property owners whose properties adjoin the project site property.

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SECTION I - CERTIFICATION AND SIGNATURE:
Please sign, indicate title and date in the appropriate locations. The Joint Permit Application package will
not be accepted unless the original form and copy are signed and dated by the applicant/owner and
witnessed.
Clarification on applicant/owner signature:
Individual –The Registration form must be signed by all owners listed within the deed of the
property or lease/rental agreement with their original signatures.
For Individual(s), no
indication of title is necessary
.
Corporations –The Registration form must be signed by the President or Vice President,
Attested by the Secretary (Assistant Secretary) or Treasurer (Assistant Treasurer).
If others are signing on behalf of the corporation,
a document evidencing delegation of
contracting authority must be provided. Acceptance of the delegated documentation is
at the sole discretion of DEP. Absent satisfactory documentation of signatory authority,
only the above officers will be accepted as appropriate signatories.
Government agencies –The Registration form must be signed by the Chief Officer or the
President/Vice President of the government agency, if incorporated. Chief Clerk, Secretary
or Treasurer Signature is required to witness or attest.
Partnerships –The Registration form must be signed by either one general partner to bind
the partnership or all partners must sign. For Limited Partnerships (LP), where each
individual is a general partner, any general partner may sign. If a corporation is a general
partner, the signage must 1) indicate the name of the corporation, 2) that it is a general
partner, and 3) the signature of the President or Vice President
and
the signature of the
Secretary or Treasurer.
If others are signing on behalf of the Limited Partnership,
a document evidencing
delegation of contracting authority must be provided.
Acceptance of the delegated
documentation is at the sole discretion of DEP. Absent satisfactory documentation of
signatory authority, only the above officers will be accepted as appropriate signatories.
Limited Liability Companies –The Registration form must be signed by a member for a
Limited Liability Company (LLC), where it is member managed; where it is manager
managed, a manager must sign. Please indicate whether the person is signing as a
“Member”
or
as
a
“Manager”
of
the
LLC, y accordi
Company Operating Agreement.
If
anyone
other
than
a
“Member”
or
“Manager”
documentation of authority to sign on behalf of the LLC must be provided.

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APPENDIX I
PERMIT WAIVERS
I-1
"§ 105.12. Waiver of permit requirements.
(a)
Under section 7 of the act (32 P.S. § 693.7), the requirements for a permit are waived for the
following structures or activities, regardless of when commenced. If the Department upon
complaint or investigation finds that a structure or activity which is eligible for a waiver, has
a significant effect upon safety or the protection of life, health, property or the environment,
the Department may require the owner of the structure to apply for and obtain a permit under
this chapter.
(1)
A dam not exceeding 3 feet in height in a stream not exceeding 50 feet in width,
except wild trout streams designated by the Fish Commission.
(2)
A water obstruction in a stream or floodway with a drainage area of 100 acres or less.
This waiver does not apply to wetlands located in the floodway.
(3)
An aerial crossing of a non-navigable stream or wetland by electric, telephone or
communication lines which are not located in a Federal wilderness area or
watercourse or body of water designated as a wild or scenic river under the Wild and
Scenic Rivers Act of 1968 (16 U.S.C.A. §§ 1271-1287) or the Pennsylvania Scenic
Rivers Act (32 P.S. §§ 820.21-820.29).
This waiver applies to one or more wires
attached aboveground to single poles. This does not apply to the maintenance and
construction of towers, roads or other water obstructions or encroachments.
(4)
A dam subject to the requirements of the Mine Safety and Health Administration,
30 CFR 77.216-1 and 77.216-2 (relating to water, sediment or slurry impoundments
and impounding structures; identification; and water, sediment, or slurry
impoundments or impounding structures; minimum plan requirements; changes or
modifications; certification), if the Department determines on the basis of preliminary
data submitted by the applicant that the dam is of a Size Classification C and Hazard
Potential Classification 3 as defined in § 105.91 (relating to classification of dams and
reservoirs) and is not located in a watercourse or body of water designated as a wild
and scenic river under the Wild and Scenic Rivers Act of 1968 or the Pennsylvania
Scenic Rivers Act.
(5)
A water obstruction or encroachment located in, along, across or projecting into a
wetland or impoundment, constructed and maintained for the purpose of treating acid
mine drainage, sewage or other waste, if the wetland or impoundment is a treatment
facility constructed under a valid permit issued by the Department under the Surface
Mining Conservation and Reclamation Act (52 P.S. §§ 1396.1-1396.31), The Clean
Streams Law (35 P.S. §§ 691.1-691.1001), the Noncoal Surface Mining Conservation
and Reclamation Act (52 P.S. §§ 3301-3326), the Solid Waste Management
Act (35 P.S. §§6018.101-6018.1003), the Oil and Gas Act (58 P.S. §§601.101-601.605)
and the Pennsylvania Sewage Facilities Act (35 P.S. §§750.1-750.20).
(6)
A water obstruction or encroachment located in, along, across or projecting into a
stormwater management facility or an erosion and sedimentation pollution control
facility which meets the requirements in Chapter 102 (relating to erosion control), if
the facility was constructed and continues to be maintained for the designated
purpose.

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APPENDIX I
PERMIT WAIVERS
I-2
(7)
Maintenance of field drainage systems that were constructed and continue to be used
for crop production. Crop production includes:
(i)
Plowing, cultivating, seeding, grazing or harvesting.
(ii)
Crop rotation.
(iii)
Government set aside programs.
(8)
Plowing, cultivating, seeding or harvesting for crop production.
(9)
Construction and maintenance of ford crossings of streams for individual private
personal use which require only grading of banks for approach roads and the
placement of not more than 12 inches of gravel for roadway stability. Fords may not
be used for commercial purposes and shall cross the regulated waters of this
Commonwealth in the most direct manner. This waiver does not apply in exceptional
value streams as listed under Chapter 93 (relating to water quality standards) or in
wild trout streams.
(10)
A navigational aid or marker, buoy, float, ramp or other device or structure for which
a permit has been issued by the Fish Commission under 30 Pa. C.S. § 5123(a)(7)
(relating to general boating regulations).
(11)
The removal of abandoned dams, water obstructions and encroachments if the
Department determines in writing on the basis of data, information or plans submitted
by the applicant that the removal of the abandoned dam, water obstruction or
encroachment cannot imperil life or property, have significant effect on coastal
resources or have an adverse impact on the environment, and the plans provide for
restoration and stabilization of the project area.
(12)
The construction, operation or removal of staff gages, water recording devices, water
quality testing devices, including, but not limited to, sensors, intake tubes, weirs and
small buildings which contain required instruments and similar scientific structures.
(13)
A bridge or culvert purchased from an operating railroad company subsequent to the
abandonment of the railroad line, track, spur or branch pursuant to the approval of
the Interstate Commerce Commission.
Major maintenance or reconstruction, or
stream dredging may not be undertaken until the new owner obtains a permit under
this chapter.
(14)
The maintenance of an artificial pond or reservoir to its original storage capacity
where:
(i)
The contributory drainage area is less than or equal to 100 acres.
(ii)
The greatest depth of water at maximum storage elevation is less than or equal
to 15 feet.
(iii)
The impounding capacity at maximum storage elevation is less than or equal
to 50 acre feet.

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APPENDIX I
PERMIT WAIVERS
I-3
(15)
The construction and maintenance of an encroachment or water obstruction on an
abandoned mining site, where the Department has issued a notice of intent to forfeit
the bond for a mining activity permitted after July 1982.
(16)
Restoration activities undertaken and conducted pursuant to a restoration plan which
has been approved, in writing, by the Department.
(b)
The requirements for a permit for existing structures or activities, as provided in section 6(c)
of the act (32 P.S. § 693.6(c)), are waived for the following structures or activities, if
construction was completed prior to July 1, 1979. If the Department upon complaint or
investigation finds that a structure or activity which is eligible for a waiver, has a significant
effect upon safety or the protection of life, health, property or the environment, the
Department may require the owner of the structure or activity to apply for and obtain a
permit under this chapter.
(1)
A dam not exceeding 5 feet in height in a nonnavigable stream operated and
maintained for water supply purposes.
(2)
A dam which the Department determines, on the basis of preliminary data submitted
by the applicant, is of Size Classification C and Hazard Potential Classification 3, as
defined in § 105.91 and does not have a significant effect on coastal resources or an
adverse impact on the environment.
(3)
A fill not located on navigable lakes and navigable rivers.
(4)
A streambank retaining device.
(5)
A stream crossing other than a crossing located on submerged lands of this
Commonwealth and a crossing by pipelines for conveyance of petroleum products
and gas.
(6)
An outfall, headwall or water intake structure.
(7)
A culvert, bridge or stream enclosure on a watercourse where the drainage area
above the culvert, bridge or stream enclosure is 5 square miles or less.
(c)
Structures and activities shall meet the construction, operation, maintenance, monitoring
and other requirements of this chapter. No other permits which may be required under a law
other than the act are waived by this section."
Note: Fish Commission references are now Fish and Boat Commission.

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APPENDIX II
GENERAL PERMITS
II-1
BWEW-GP-1 FISH HABITAT ENHANCEMENT STRUCTURES
Used for the installation, operation and maintenance of fish habitat enhancement structures in the
regulated waters of this Commonwealth.
BWEW-GP-2 SMALL DOCKS AND BOAT LAUNCHING RAMPS
Used for the installation, operation, modification and maintenance of small docks and boat launching
ramps in and along the regulated waters of this Commonwealth.
BWEW-GP-3 BANK REHABILITATION, BANK PROTECTION AND GRAVEL BAR REMOVAL
Used for the installation, operation, modification and maintenance of bank rehabilitation and protection
projects and the removal of gravel bars in and along the regulated waters of this Commonwealth.
BWEW-GP-4 INTAKE AND OUTFALL STRUCTURES
Used for the construction, operation and maintenance of intake and outfall structures in, along, across or
projecting into the regulated waters of this Commonwealth.
BWEW-GP-5 UTILITY LINE STREAM CROSSINGS
Used for the installation, operation and maintenance of utility line stream crossings of the regulated
waters of this Commonwealth.
BWEW-GP-6 AGRICULTURAL CROSSINGS AND RAMPS
Used for the installation, operation and maintenance of agricultural crossings and ramps in the regulated
waters of this Commonwealth.
BWEW-GP-7 MINOR ROAD CROSSINGS
Used for: (1) the construction, operation and maintenance of a minor road crossing across wetlands
which disturbs less than 0.1 acre of wetlands; (2) the construction, operation and maintenance of a minor
road crossing across a stream where the watershed drainage is 1.0 square mile or less; and (3) the
removal of an existing minor road crossing across a stream where the drainage area is 1.0 square mile or
less.
BWEW-GP-8 TEMPORARY ROAD CROSSINGS
Used for the construction, operation and maintenance of temporary road crossings of the regulated
waters of this Commonwealth.
BWEW-GP-9 AGRICULTURAL ACTIVITIES
Used for the installation, operation, modification and maintenance of certain agricultural activities that
encroach into streams and their floodways or bodies of water wholly or partially within or forming part of
the boundary of this Commonwealth. Such approved activities include grassed or lined waterways,
terraces, diversions, waste storage facilities, spring development and minor drainage that supports these

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APPENDIX II
GENERAL PERMITS
II-2
activities and is necessary for contour strips when engaged in as a part of an existing agricultural
operation and shall only be implemented as part of a conservation plan consistent with the 25 PA Code,
Chapter 102 Regulations and approved by the county conservation district.
BWEW-GP-10 ABANDONED MINE RECLAMATION
Used for 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.
BWEW-GP-11: MAINTENANCE, TESTING, REPAIR, REHABILITATION, OR REPLACEMENT OF
WATER OBSTRUCTIONS AND ENCROACHMENTS
Authorizes the maintenance, testing, repair, rehabilitation and replacement of existing water obstructions
and encroachments including currently serviceable bridges, culverts, utility lines, and docks.
The
applicant will be required to register the project by submitting written notice and all applicable information
to the department.
BWEW-GP-15 PRIVATE RESIDENTIAL CONSTRUCTION IN WETLANDS
Used for the placement and maintenance of fill in, or the excavation of, non-tidal wetlands for the
construction or expansion of a single family home for the personal residence of the permittee, including
reasonable and necessary features such as a driveway, storage shed and utilities on a residential lot
purchased by the permittee prior to November 22, 1991, within established subdivisions approved by the
local governing authority where such activities do not impact greater than 0.50 acre of non-tidal wetlands.

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APPENDIX III
OUTLINE FOR SUGGESTED HYDROLOGY AND HYDRAULICS REPORT FORM
III-1
The following is an outline for suggested Hydrology and Hydraulics report format.
HYDROLOGY AND HYDRAULIC REPORT
(NAME OR IDENTIFICATION NUMBER OF STRUCTURE/ACTIVITY)
(STATION #, MILE POST MARKER # OR OTHER SPECIAL IDENTIFICATION)
(NAME OF STREAM, RIVER OR BODY OF WATER IF NOT LISTED ABOVE)
(MUNICIPALITY)
(COUNTY)
1.
SITE HISTORY AND CONDITIONS
a.
Flood records
b.
Site conditions
2.
HYDROLOGY
a.
Rainfall determinations
b.
Runoff calculations or listing of existing determinations.
3.
HYDRAULIC ANALYSIS
a.
Hydraulic calculations for capacity of existing and proposed conditions.
b.
Flood water surface calculations/determinations (develop profiles, maps and cross
sectional drawings).
c.
Streambed/streambank stabilization study. Design of remedial measures.
d.
Determination if Risk Assessment is required.
e.
Attachments, computer runs, etc.

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APPENDIX IV
SAMPLE - REQUIREMENTS FOR A PROPOSED BRIDGE
IV-1
The following is provided as an example of requirements for a proposed bridge (Subchapter C) and a
recommendation on how to complete these requirements.
EXAMPLE 1: PROPOSED BRIDGE
"Subchapter C. CULVERTS AND BRIDGES
PERMITS
§ 105.151. Permit applications for construction or modification of culverts and bridges.
In addition to the information required under § 105.13 (relating to permit applications—information and
fees), applications for permits under this subchapter for the construction or modification of culverts
and bridges shall contain the following:
(1)
Plans showing the location, type, size and height of the proposed bridge or culvert and
detailing the topographic features, elevations and structures so as to enable an appraisal of
the hazard potential of the structure."
[This is basically a duplication of the "site plan"
requirement specified under Section 105.13(d)(1)(i). Accordingly, a separate "H & H" site plan is
not required.]
(2)
"A description of the character of the stream bed and banks and a profile of the stream for a
reasonable distance above and below the proposed site, showing slopes of bed, normal
water surface and flood water surface."
[See Sample Drawing A2 for an example of a profile
drawing. Such profiles may be hand drawn or computer generated. When a project is located in a
FEMA flood study area, a photocopy of the FEMA profile must be used with the altered flood water
surfaces clearly shown.]
(3)
"A hydrologic and hydraulic analysis which shall include:
data on size, shape, and
characteristics of the watershed; the amount and frequency of the design flood; the
hydraulic capacity of the structure; the hydraulic capacity of the channel upstream and
downstream; and, where flooding is a problem, flood damage and backwater analysis."
[The
"hydrologic" portion of analysis will be completed as previously discussed (see pages 9-11). The
level of hydraulic analysis required (see pages 11-12) will depend on the actual structure proposed,
its impacts and the potential threat to nearby homes and other properties. New or replacement
bridges must be analyzed relative to the changes in flood water elevations between existing and
proposed conditions. In subsequent portions of this example, specific design criteria will be listed
and this must be used in the analysis.
"DESIGN CRITERIA FOR CONSTRUCTION OR MODIFICATION
§ 105.161. Hydraulic capacity
a.
Bridges and culverts shall be designed and constructed in accordance with the following criteria:
(1)
The structure shall pass flood flows without loss of stability."
[Based on the results of the
hydraulic analysis, additional calculations may be required to demonstrate that the structure will
pass design flows without damages to abutment footers, wingwalls, etc., or from overtopping during
larger flood events.]

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APPENDIX IV
SAMPLE - REQUIREMENTS FOR A PROPOSED BRIDGE
IV-1
(2)
"The structure may not create or constitute a hazard to life or property, or both."
[The results
of the hydraulic analysis must clearly demonstrate that the proposed structure will not increase flow
velocities or flood water elevations to the extent of adversely impacting or threatening life or
property.]
(3)
"
The structure may not materially alter the natural regime of the stream."
[This typically refers
to creation of standing water upstream, or increased flow velocity downstream of the proposed
structure that would permanently alter normal stream flow characteristics. The hydraulic analysis
must demonstrate that neither condition will occur.]
(4)
"
The structure may not so increase velocity or direct flow in a manner which results in
erosion of stream beds and banks."
[This refers to a change in downstream flow direction and/or
increase in flow velocity that would cause damage to the stream bed or banks. The hydraulic
analysis must demonstrate that flows exiting the structure are not sufficient to initiate erosion of the
existing stream bed or banks. If exit velocities will initiate erosion, the analysis must then include
the hydraulic design of energy dissipaters, rock riprap or similar stabilization works needed to offset
the effects of
the proposed structure.
Refer
t
Control Manual for additional discussion on design considerations for these problems.]
(5)
"
The structure may not significantly increase water surface elevations."
[This is a critical
requirement and must be analyzed on a case by case basis. See the following subsection (e) for
additional specific requirements.]
(6)
"
The structure shall be consistent with local flood plain management programs."
[This
requirement may be satisfied through compliance with Section 105.13 (d)(1)(vi) requirements. This
requirement also applies to local flood plain management programs where no detailed FEMA flood
studies have been completed.]
b.
"In determining flood flows and frequencies for purposes of this subchapter, hydrologic analysis
shall be by methods generally accepted in the engineering profession."
[Actual recommendations
have been made in the "HYDROLOGY" section (see pages 9-11).]
c.
The general criteria for design flows are as follows:
(1)
Rural area - 25-year frequency flood flow.
(2)
Suburban area - 50-year frequency flood flow.
(3)
"Urban area - 100-year frequency flood flow."
[These requirements are self explanatory. However, the Department will review, on a case by case
basis, requests to lower or raise this criteria due to geological, environmental, future development
and other unique site conditions.]
d.
"The determination of flood flows for design shall be made with reasonable consideration of
development which may alter the runoff characteristics of the watershed during the anticipated
life of the structure. Specific design requirements in subsection (c) may be varied to fit the
conditions at the site and the requirements of flood plain management regulations and
ordinances."
[This requires the applicant to check with the local municipality and/or county planning
commission to determine projected development in the watershed and to determine any municipal design

3150-PM-BWEW0036
8/2016
Instructions
APPENDIX IV
SAMPLE - REQUIREMENTS FOR A PROPOSED BRIDGE
IV-3
requirements in excess of those listed in subsection (c). Based on the results of such inquiry, the design
flow for the project may be adjusted to fit these requirements.]
e.
"The structure shall pass the 100-year frequency flood with less than a 1.0-foot increase in the
natural unobstructed 100-year water surface elevation, except where the structure would be
located in a floodway which is delineated on a FEMA map, in which case no increase in the
100-year water surface elevation will be permitted. Exceptions to this criteria may be approved by
the Department if the applicant prepares a risk assessment which demonstrates, and the
Department finds, that the structure will not significantly increase the flooding threat to life and
property or the environment, and if applicable, is consistent with the municipal floodplain
management programs adopted under the National Flood Insurance Program and a FEMA Flood
Insurance Study. This information may be obtained from the Department of Community and
Economic
Development,
Governor’s
Center 4thfor
Floor, Loca
Commonwealth Keystone Building, Harrisburg, Pennsylvania 17120."
[This requires that a
hydraulic analysis be performed that clearly demonstrates that the proposed work will not cause more
than the allowable increase in flood water surface elevations. If the analysis shows more than the
allowable increase, then the applicant should consider project redesign. If a redesign is not possible,
then a risk assessment must be prepared and attached to the application package. The applicant would
mark "Y" (Yes) for the "Risk Assessment" (Section F o) on the Application Completeness Checklist on
Page 2 of the application. The Risk Assessment must clearly demonstrate that the increased flood water
surfaces will not cause an increased flooding threat to life, property or the environment. When located in
a FEMA flood study area, the Risk Assessment must include documentation that the municipality has
contacted FEMA about the proposed flood water surface increases and will be taking those necessary
steps to revise the FEMA flood study to reflect such increases.]
****The above provides a good example of how, in completing one mandatory permit application
requirement, the need for a secondary requirement is established. In this case, if the hydraulic
analysis shows flood water surface increases within the allowable limits, no risk assessment would
be required and on page 2 of the application, an entry of "N/A" (not applicable) would be made for
"Section F o" of the Application Completeness Checklist. If the allowable limits are exceeded, then
the Risk Assessment must be prepared and "Section F o" on the checklist would be marked with a
"Y" (yes).
The example will end at this point. However, the applicant should be aware that if working on a real
application, similar considerations as discussed would be required for the remaining
subsections 105.162 through 105.166, concerning culverts and bridges.

3150-PM-BWEW0036
8/2016
Instructions
APPENDIX V
LETTER FROM APPLICANT TO MUNICIPALITY AND COUNTY
TO SATISFY ACTS 14, 67, 68 and 127
V-1
Note: This letter may be duplicated and used as a fill-in form letter, with one copy to be
addressed and sent certified mail to the County Commissioners or Clerk for county
notification; and to the Secretary, Township Supervisors, Manager, Mayor or Borough Council,
as appropriate for municipal notification.
Date
Dear
:
The purpose of this notice is to inform you of our intent to submit an application to the Pennsylvania
Department of Environmental Protection (DEP) for the following application:
1.
Project Name:
2.
Project Description:
3.
Applicant Name:
4.
Applicant Contact:
(provide name, address and phone #)
5.
Site Location:
6.
Municipality/County:
Section 1905-A of the Commonwealth Administrative Code, as amended by Act 14, requires that each
applicant for a DEP permit must give written notice to the municipality(ies) and the county(ies) in which the permitted
activity is located. The written notices shall be received by the municipality(ies) and county(ies) at least 30 days before
the Department may issue or deny the permit.
"Acts 67 and 68, which amended the Municipalities Planning Code to support sound land use practices and
planning efforts, direct state agencies to consider comprehensive plans and zoning ordinances when reviewing
applications for permitting of facilities or infrastructure, and specify that state agencies may rely upon comprehensive
plans and zoning ordinances under certain conditions as described in Sections 619.2 and 1105 of the Municipalities
Planning Code. Enclosed is a General Information Form (GIF) we have completed for this project. DEP invites you to
review the attached GIF and comment on the land use aspects of this project; please be specific to DEP when
identifying any areas of conflict. If you wish to submit comments for DEP to consider in a land use review of this project,
you must respond within 30 days to the DEP regional office listed below. If there are no land use comments received
by the end of the comment period, DEP will assume that there are no substantive land use conflicts and proceed with
the normal application review process."
Please submit any comments concerning this project within 30 days from date of receipt of this letter to the
DEP Waterways and Wetland Program at
.
For more information about this land use review process, please visit
www.dep.pa.gov
, (keyword: Land Use
Reviews).
Sincerely,
Enclosure (completed GIF)

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
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

1300-PM-BIT0001
5/2012
Instructions
Page 1 of 12
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
GENERAL INFORMATION FORM -- AUTHORIZATION APPLICATION
INSTRUCTIONS
GENERAL INFORMATION
To Obtain DEP Application Packages.
To expedite the processing of the applicant’s
request, the Department of Environmental Protection (DEP) asks that you use the most
up-to-date application package available. The most recent version of this General
Information Form (GIF) package can be obtained by contacting the appropriate DEP
office, or through our website noted below. This package, as well as other Department-
wide and/or Program-Specific Permit Application Form Packages are available in
Microsoft Word format at this same web location. Applicants can download the
appropriate form to a personal computer, complete the form electronically, and print the
document for submittal to the Department.
Access:
www.depweb.state.pa.us
Select:
Permits, Licensing & Certification
Select:
Department-Wide Permit/Authorization Packages
Select:
General Information Form (GIF)
General Instructions.
This package is designed to assist the applicant in completing
the General Information Form (GIF) and in determining which environmental permits or
approvals are needed for the project. Please type or print clearly when completing the
form. If information needed is more than space allows, attach additional sheets as
necessary. If a question is not applicable to you or your project, write NA in the
appropriate box.
For example -- application is in reference to the Act 537 Program.
Many GIF questions may not apply to this type of applicant; but program-specific forms
for that particular program will need more information from the applicant.
A full application for a particular DEP permit or other authorization will generally consist
of this GIF and additional forms related to the particular permit or other authorization.
Individual applications may require more detailed information, such as site drawings
and more detailed applicant information. Moreover, an applicant may need to provide
proof of financial responsibility (such as performance bonds, insurance policies, or
both) in order to qualify for some DEP permits or authorizations. These requirements
vary by program. Be sure to ask each program whether you must supply financial
responsibility documents in order to obtain your permit or other authorization.

1300-PM-BIT0001
5/2012
Instructions
Page 2 of 12
If multiple applications are submitted, only one GIF need be submitted with the various
program-specific applications. If the applications are submitted at different times, the
applicant may photocopy the most up-to-date version of the GIF or refer to the
Application Processing System (APS) coordination number assigned by DEP (if known)
when submitting forms.
DEFINITIONS
To provide the applicant with a better understanding of terminology, we are including
the following definitions.
eFACTS (Environment, Facility, Application, Compliance Tracking System).
The
Department of Environmental Protection’s electronic application system to document
and maintain client, site and facility data for purposes of authorizing regulated activities
and tracking compliance.
eNotice.
DEP has developed a comprehensive environmental compliance information
reporting system to give the public access to permitting and compliance information on
individual facilities by program and by geographic area. This system is available by
logging on to the DEP website and selecting eNOTICE.
Client (Responsible Party).
A client (also referred to as Applicant) is a person or
organization that requests approval from DEP to perform a regulated activity. Client
information is documented and assigned an internal DEP Client ID# for tracking
purposes.
Site (Place).
A site is a physical location of importance to DEP. A site may include
locations where a regulated facility is physically located or where a regulated activity
occurs that has the potential to impact the health and safety of the citizens and/or the
natural resources of the Commonwealth. A site is not solely defined by geographical
location (can span several municipalities and even counties in some cases) but rather
by the client/applicant’s purpose of doing business. All DEP programs involvement at a
physical location of importance to DEP is grouped under one ‘entity’ – site. This holistic
view of site will promote an understanding of the interrelationships of facilities to
support pollution prevention; multi-media inspections; a Department-wide view of
compliance; and public understanding and access of information. Site information is
documented and assigned an internal DEP Site ID# for tracking purposes.
Site-to-Client Relationships.
DEP will create internal records to relate (link) each site
with all clients associated with the site and/or its facilities.

1300-PM-BIT0001
5/2012
Instructions
Page 3 of 12
Facility.
A facility (also referred to as Primary Facility (PF)) is a logical bridge between
sites and sub-facilities that allows DEP to provide a framework for a facility’s or an
activity’s regulation. Primary facility is a way to group a program’s involvement at a site
(what it regulates) under one heading. For example: The Coal Mining program groups
all of their involvement (regulated entities) under the Primary Facility type of ‘Coal
Mining Operations’. Facility information is documented and assigned an internal DEP
Facility ID# for tracking purposes.
Other examples of PFs are:
Water Pollution Control Facility
Radiation Facility
Oil & Gas Location
Water Resource
Air Emissions Plant
Encroachment Location
Sub-Facility.
A sub-facility (SF) is program-specific. A sub-facility is what DEP
regulates. For example: A Deep Mine is a sub-facility of a Coal Mining Operation
primary facility.
Other examples of PFs and associated SFs are:
Primary Facility (PF)
Sub-Facility (SF)
Water Pollution Control Facility
Treatment Plant
Discharge Point
Radiation Facility
X-ray Machine
Radioactive Materials
Oil & Gas Location
Well
Pit
Water Resource
Surface Water Withdrawal
Groundwater Withdrawal
Air Emissions Plant
Incinerator
Process
Encroachment Location
Bridge
Dock
Project.
A project includes all the construction, installation, and/or renovation needed
to achieve the applicant’s goal. An applicant must obtain all required permits/approvals
from DEP before beginning regulated activities or the construction or expansion of a
regulated facility. Project information is documented and assigned an internal DEP
application processing system number (APS ID#) for tracking purposes.
Authorization.
Any DEP approval. For example: permits, plans, approvals, licenses,
registrations, certifications, etc. Authorization information is documented and assigned
an internal DEP Auth ID# for tracking purposes.

1300-PM-BIT0001
5/2012
Instructions
Page 4 of 12
Permit Coordination.
Projects that need more than one permit/approval from DEP are
coordinated so that the permits/approvals are normally issued simultaneously.
CLIENT INFORMATION
DEP Client ID#.
Department-wide unique identification number assigned by DEP to
the client after client information is entered into DEP’s computer system. This one
number identifies the client regardless of the program with which the client is working.
This identification number will be identified on future correspondence from DEP as well
as on client information available on our DEP website. When replying to DEP, inclusion
of this number will make it easier to process your request in a timely manner. If you
know your Client ID#, enter it. If you are a new client to DEP, skip to the next request
for information.
Client Type Code.
Enter the code that represents the type of client acting as the
responsible authority for the permitted activity. The list of Client Type Codes can be
found on the list of Type Codes included at the end of this instruction document.
Organization Name or Registered Fictitious Name.
Clients other than individuals
must provide the name under which they conduct the activity or business in which the
permit or other authorization will be issued.
Individuals should complete the “Organization Name” if they conduct their business or
activity under a name other than their own (for example, “Jones Construction
Company”, rather than “Mary Jones”).
For partnerships, be sure to list the business name of the partnership as it appears on
legal partnership papers.
If the applicant is an individual(s) or partnership, be sure to also provide the appropriate
information on the individual name lines.
Employer ID#.
Also referred to as “Federal Tax ID#”. The EIN aids DEP in identifying
the organization and prevents duplicate
data entry from occurring. This information is
required.
Dun & Bradstreet ID#.
If known, supply the applicant’s Dun & Bradstreet Identification
Number. This information is optional.
Individual Last Name, First Name, MI, Suffix, Social Security Number.
This
information, with the exception of the SSN, must be provided for applicants who are
individuals or partnerships. The SSN aids DEP in identifying the individual and
prevents duplicate data entry, although, it is optional. This information is not accessible
by the public or other government agencies.

1300-PM-BIT0001
5/2012
Instructions
Page 5 of 12
Additional Individual Last Name, First Name, MI, Suffix, Social Security Number.
This information, with the exception of the SSN, must be provided for additional
applicants who are individuals or partnerships. The SSN aids DEP in identifying the
individual and prevents duplicate data entry, although, it is optional. This information is
not accessible by the public or other government agencies.
Mailing Address.
The mailing address of the client identified above (this should
not
include locational data that is not appropriate for a mail piece). In addition to the street
number and name, PO Box#, RR# Box#, or Highway Contract# designations, use any
appropriate designation and number to further define the mailing address of the
applicant.
e.g.,
APT
(Apartment)
DEPT
(Department)
RM
(Room)
BLDG
(Building)
FL
(Floor)
STE
(Suite)
City, State, ZIP+4, Country.
Enter an appropriate city, borough, or town designation
(do not enter a township designation in this area). Do
not
use abbreviations for the city
name. Use the two-character abbreviation for the state. Include the four-digit
extension to the ZIP code. If other than USA, provide country.
Client Contact Information.
Clients that are organizations must provide the name of a
person representing the client (organization). This client contact must be an employee
of the organization and must be located at the mailing address of the client and may
receive correspondence on behalf of the client. Include the individual’s name, title,
daytime phone number, and email address. The Department will use this contact
information for maintaining client data. This individual should be a high-level employee
such as CEO, VPs, Operations Manager, etc. or someone
capable of answering
informational questions regarding the organization such as EIN, fictitious name
ownership, address data, related organizations, corporate changes, etc. Project
contact information should be entered in the Site Contact found in the Site Information
section.
SITE INFORMATION
DEP Site ID#.
Department-wide unique identification number assigned to the site after
site information is entered into DEP’s computer system. This one number identifies the
site regardless of the program with which the applicant is working. This identification
number will be identified on future correspondence from DEP as well as on site
information available on our DEP website. When replying to DEP, inclusion of this
number will make it easier to process your application in a timely manner. If you know
your Site ID#, enter it. If you are identifying a new site to DEP, skip to the next request
for information.
Site Name.
The name of the site at the specific physical location. Do not use
abbreviations, acronyms, etc.
EPA ID#.
If known, supply the EPA ID# for the site (this number is also referred to as a
FINDS ID#). This is optional.

1300-PM-BIT0001
5/2012
Instructions
Page 6 of 12
Estimated Number of Employees to be Present at Site.
To assist with future
Pollution Prevention and Compliance Assistance initiatives, please include the
estimated number of employees to be present at the site once it is active.
Description of Site.
Provide a written description of the proposed site (e.g., water
treatment plant, sewage treatment plant, toy factory, etc.).
County, Municipality, State.
Indicate the county(ies) and municipality(ies) in which the
site is located. Check the appropriate box to identify the type of municipality entered
(city, borough, township). Include the two-character abbreviation for the state.
Site Location.
Provide the physical address of the location where the permitted
activities will occur. No PO Box Numbers will be accepted for site location information.
Provide the City (or municipality), State, and the ZIP+4, if known.
Detailed Written Directions to Site.
When providing written directions, do not use
PO Box address data. Include landmarks and approximate distances from the nearest
highway.
Site Contact Information.
Provide the name of the person having overall responsibility
for environmental matters at the site. Include the individual’s name, title, firm, mailing
address, daytime phone number, and email address (optional).
NAICS Codes.
Clients applying for an authorization from DEP need to provide the
appropriate North American Industry Classification System (NAICS pronounced nākes)
code(s) at the Sector level (at a minimum). Enter all NAICS codes that pertain to the
activity for which the application is being completed. More than one two-digit or three-
digit NAICS code may be entered in the box provided. If you know your
six
-digit NAICS
code, enter it in the optional box provided. The most up-to-date list of NAICS sector
and subsector codes can be found on the NAICS website (part of the US Census
Bureau) at
http://www.census.gov/eos/www/naics/
or by contacting a DEP office
identified at the end of this instructions document.
Site-to-Client Relationship.
Enter the relationship code that best describes how the
client is related to the activity or operation at the site for which the permit or other
authorization is being sought. The list of Site-to-Client Relationship Codes can be
found on the list of Type Codes included at the end of this instructions document.
FACILITY INFORMATION
Modification of Existing Facility.
If this project is to modify an existing facility,
system, or activity, indicate the facility type and its DEP facility identification number.
Latitude / Longitude.
Latitude and longitude measures aid in providing the physical
location of the facility. If known, indicate appropriate degrees, minutes, and seconds for
the project. The Latitude/Longitude Point of Origin is the place or location where the
reading was actually taken.

1300-PM-BIT0001
5/2012
Instructions
Page 7 of 12
Additional Locational Data Information.
This information is being requested in order
to determine the method, accuracy and description of the latitude and longitude
information that is being provided with the application. If known, please provide this
information for your locational data. The list of locational data codes and descriptions
can be found by referencing ‘GIF Locational Data Codes’. This document can be found
on the DEP website with this GIF package or by contacting a DEP office identified at
the end of this instructions document.
PROJECT INFORMATION
Project Name.
Provide the name by which this proposed activity or project is, or will
be, known (e.g., XYZ Sub-Division, ABC Plant Expansion).
Project Description.
Provide a detailed description of the project. If applying for a part
of a larger project, broadly describe the entire project (e.g., a pipe crossing to serve the
XYZ Sub-Division).
Project Consultant Information.
Provide the name of the consultant for this project, if
applicable. Include the individual’s name, title, firm, mailing address, daytime phone
number, and email address (optional).
Time Schedules / Project Milestones.
Provide the proposed schedule of project
milestones, if any (e.g., 09-15-2002 Proposed Construction Start Date).
Project’s Land Use.
The answer provided to Question 3 in the Project Information
section will determine whether this project is subject to the Land Use Policy.
Authorization/application types that are affected by DEP’s Land Use Policy are attached
to these instructions as Appendix A. For detailed instructions on how to complete this
section, see the Department's Policy for Consideration of Local Comprehensive Plans
and Zoning Ordinances in DEP Review of Authorizations for Facilities and Infrastructure
- Document ID: 012-0200-001. If you are not sure if your authorization/application type
is affected by the Land Use Policy, please contact the appropriate DEP office.
LAND USE INFORMATION
Applicants can choose an early opt-out option but are required to attach documentation
indicating zoning approval from the municipal governing bodies where the project is
being proposed. For more information, see the Department's Policy for Consideration
of Local Comprehensive Plans and Zoning Ordinances in DEP Review of
Authorizations for Facilities and Infrastructure - Document ID: 012-0200-001. If the
applicant chooses the early-opt out option and zoning approval documentation is
attached, the Land Use Information section does not need to be completed.

1300-PM-BIT0001
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Instructions
Page 8 of 12
If the applicant does not choose the early opt-out option and the authorization/
application type is listed in Appendix A, the applicant must complete the Land Use
Information section. For detailed instructions on how to complete this section, see the
Department's Policy for Consideration of Local Comprehensive Plans and Zoning
Ordinances in DEP Review of Authorizations for Facilities and Infrastructure -
Document ID: 012-0200-001
COORDINATION INFORMATION
Multiple authorizations are often required for residential, commercial, or industrial land
development. This section is vital in determining if any other environmental permits or
approvals are needed for your project.
Special Note:
By completing this section, you will assist DEP
and County
Conservation Districts
in coordinating all authorizations that may be required for your
project. County Conservation District approval does not automatically guarantee the
issuance of other permits for your project, nor does it relieve you of the responsibility of
making timely application for other necessary permits. Note that local municipal
approvals may also be required before the project can be initiated. If your proposal will
generate sewage, the local municipality will need to review its sewage plan and receive
approval from DEP prior to your submission. In addition, please note that even though
you may soon receive a General Permit authorization, other permit requirements may
preclude site development or other activities until all permits are issued.
What Your “Yes” Answers Mean.
If you answer “Yes” to any of the questions in this
section, you will probably need a specific permit or approval from DEP. Refer to the
information provided at the end of these instructions that identifies specific regional,
central, and district offices. Contact the appropriate DEP office to further discuss the
need for an authorization. If additional applications are necessary, they will be mailed
to you.
If “Yes” to Question,
Contact:
1.0
District Mining Permitting Section
1.1 to 1.3
Regional Air Quality Program
1.4
Regional Water Quality Permitting Section
1.5
Central Office Dam Safety Division
1.6
Regional Oil & Gas Program (located only in NC, SW & NW Regional Offices
)
2.0
District Mining Permitting Section
2.1 to 2.3
Regional Air Quality Program
2.4
Regional Water Quality Permitting Section
2.5
Central Office Dam Safety Division
3.0 to 3.3
Regional Oil & Gas Program
(
located only in NC, SW & NW Regional Offices
)
4.0 to 5.0
Local County Conservation District -
or
- Regional Soils & Waterways Section
6.0 to 8.0
Regional Water Quality Permitting Section
9.0
Regional/District Water Quality Planning Section
10.0
Regional Water Quality Operations Section
11.0 to 12.0
Central Office Dam Safety Division
If “Yes” to Question,
Contact:
13.0
Regional Air Quality Program

1300-PM-BIT0001
5/2012
Instructions
Page 9 of 12
14.0 to 17.0
Regional Water Supply Mgmt Program -
and
- Watershed Management
Program
18.0
Regional Waste Management Program
19.0
District Mining Permitting Section
20.0 to 23.0
Central Office Storage Tanks Division
24.0
Regional Radiation Protection Program (located only in SE, SC, SW Regional
Offices)
CERTIFICATION
A legally responsible agent of the client should complete and sign the certification.
APPLICANT’S CHECKLIST
To assure your application is complete, we are providing a convenient checklist of what
may need to be attached to the application as well as who to contact for additional
information. This checklist is optional and need not be returned with the completed
application.
TYPE CODES
The following list of codes is to identify specific types of requested information.
CLIENT INFORMATION. Client Type / Codes
Government
Non-Government
Individual
AUTH
Authority
ASSOR
Association/Organization
INDIV
Individual
CNTY
County
LLC
Ltd Liability Company
FED
Federal Agency
LLP
Ltd Liability Partnership
MUNI
Municipality
NPACO
Non-Pennsylvania Corporation
NONPG
Non-PA Govt
OTHER
Other (Non-Govt)
OTHG
Other (Govt)
PACOR
Pennsylvania Corporation
SCHDI
School District
PARTG
Partnership-General
STATE
State Agency
PARTL
Partnership-Limited
SOLEP
Sole Proprietorship
Note:
If two individuals’ names are listed as the application’s clients, the Client Type Code of
“Partnership/General” should be used.
SITE INFORMATION. Site-to-Client Relationship Codes
Code
Type
Code
Type
OWN
Owner
LESOP
Lessee / Operator
OPR
Operator
CONTR
Contractor for Owner or Operator
OWNOP
Owner/Operator
AGENT
Agent for Owner or Operator
LESSE
Lessee
OTHER
Other (Explain)

1300-PM-BIT0001
5/2012
Instructions
Page 10 of 12
DEP OFFICES
The following information is to assist the client with appropriate contact information
when addressing the Department. Listed below is information for regional, central, and
district mining offices and the counties they serve.
REGIONAL OFFICES
PA Dept of Environmental Protection
SE Regional Office
2 E. Main Street
Norristown PA 19401-4915
(484) 250-5900
SERO Counties: Bucks, Chester, Delaware,
Montgomery, and Philadelphia. Oil & Gas issues
should be addressed to NC Regional Office for
these counties.
Note:
Air Quality in the City of Philadelphia is
regulated by the Philadelphia Health Department,
Division of Air Management Services (AMS).
Information on AMS permitting requirements can
be obtained by calling 215-685-7572.
PA Dept of Environmental Protection
NE Regional Office
Two Public Square
Wilkes Barre PA 18701-1915
(570) 826-2511
NERO Counties: Carbon, Lackawanna, Lehigh,
Luzerne, Monroe, Northampton, Pike, Schuylkill,
Susquehanna, Wayne, and Wyoming. Oil & Gas
issues should be addressed to NC Regional Office
for these counties.
PA Dept of Environmental Protection
SC Regional Office
909 Elmerton Ave
Harrisburg PA 17110-8200
(717) 705-4700
SCRO Counties: Adams, Bedford, Berks, Blair,
Cumberland, Dauphin, Franklin, Fulton,
Huntingdon, Juniata, Lancaster, Lebanon, Mifflin,
Perry, and York. Oil & Gas issues should be
addressed to NC Regional Office for these
counties.
PA Dept of Environmental Protection
NC Regional Office
208 W Third St Ste 101
Williamsport PA 17701
(570) 327-3636
NCRO Counties: Bradford, Cameron, Clearfield,
Centre, Clinton, Columbia, Lycoming, Montour,
Northumberland, Potter, Snyder, Sullivan, Tioga,
and Union. Oil & Gas issues should be addressed
to NC Regional Office for these counties.
PA Dept of Environmental Protection
SW Regional Office
400 Waterfront Dr
Pittsburgh PA 15222-4745
(412) 442-4000
SWRO Counties: Allegheny, Armstrong, Beaver,
Cambria, Fayette, Greene, Indiana, Somerset,
Washington, and Westmoreland.
PA Dept of Environmental Protection
NW Regional Office
230 Chestnut St
Meadville PA 16335-3481
(814) 332-6945
NWRO Counties: Butler, Clarion, Crawford, Elk,
Erie, Forest, Jefferson, Lawrence, McKean,
Mercer, Venango, and Warren.

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Instructions
Page 11 of 12
CENTRAL OFFICES
PA Dept of Environmental Protection
Dam Safety Division
PO Box 8460
Harrisburg PA 17105-8460
(717) 787-8568
PA Dept of Environmental Protection
Storage Tanks Division
PO Box 8762
Harrisburg PA 17105-8762
1-800-42TANKS (toll free within PA)
(717) 772-5599 (local & outside PA)
PA Dept of Environmental Protection
Bureau of Point and Non-Point
Source Management
Operations Monitoring & Training Division
PO Box 8774
Harrisburg PA 17105-8774
(717) 772-4018 (activities outside PA)
Appropriate Regional Office (activities in PA)
PA Dept of Environmental Protection
Bureau of Point and Non-Point
Source Management
Planning & Permits Division
PO Box 8774
Harrisburg PA 17105-8774
(717) 787-8184 (activities outside PA)
Appropriate Regional Office (activities in PA)
PA Dept of Environmental Protection
Hazardous Waste Mgmt Division
PO Box 69170
Harrisburg PA 17105-9170
(717) 787-6239
PA Dept of Environmental Protection
Municipal & Residual Waste Mgmt Division
PO Box 69170
Harrisburg PA 17105-9170
(717) 787-7381
PA Dept of Environmental Protection
Radiation Protection Bureau
PO Box 8469
Harrisburg PA 17105-8469
(717) 787-2480
PA Dept of Environmental Protection
Certification & Licensing Section
PO Box 8455
Harrisburg PA 17105-8455
(717) 772-4497 (X-Ray Equipment Renewal)
PA Dept of Environmental Protection
Certification & Licensing Section
PO Box 8454
Harrisburg PA 17105-8454
(717) 787-5236 (Water/Wastewater Certification)
(717) 787-6045 (Sewage Enforcement Office Certification & Laboratory Certification)
(717) 787-8059 (Blaster License, Storage Magazine License, Sales Permit, Explosives Purchase Permit)

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Instructions
Page 12 of 12
DISTRICT MINING OFFICES
PA Dept of Environmental Protection
Greensburg District Office
Armbrust Bldg
RR 2 Box 603-C
Greensburg PA 15601-0982
(724) 925-5500
Greensburg DO Counties: Allegheny, Armstrong,
Beaver, Fayette, Greene, Washington, and
Westmoreland.
PA Dept of Environmental Protection
Cambria District Office
286 Industrial Park Rd
Ebensburg PA 15931-4119
(814) 472-1900
Cambria DO Counties: Bedford, Blair, Cambria,
Fulton, Huntingdon, Indiana, and Somerset.
PA Dept of Environmental Protection
Pottsville District Office
5 W Laurel Blvd
Pottsville PA 17901-2545
(570) 621-3118
Pottsville DO Counties: Adams, Berks, Bucks,
Carbon, Chester, Columbia, Dauphin,
Cumberland, Delaware, Franklin, Juniata, Monroe,
Lackawanna, Lancaster, Lebanon, Lehigh,
Luzerne, Mifflin, Montgomery, Pike, Montour,
Northampton, Perry, Northumberland,
Philadelphia, Schuylkill, Snyder, Susquehanna,
Union, Wayne, Wyoming, and York.
PA Dept of Environmental Protection
Moshannon District Office
186 Enterprise Drive
Philipsburg PA 16866
(814) 342-8200
Hawk Run DO Counties: Bradford, Cameron,
Centre, Clearfield, Clinton, Potter, Lycoming,
Sullivan, and Tioga.
PA Dept of Environmental Protection
California District Office
California Tech Park
25 Technology Drive
Coal Center PA 15423
(724) 941-7100
McMurray DO Counties: All counties where mining
and subsidence occur.
PA Dept of Environmental Protection
Knox District Office
White Memorial Bldg
PO Box 669
Knox PA 16232-0669
(814) 797-1191
Knox DO Counties: Butler, Clarion, Crawford, Elk,
Erie, Forest, Warren, Jefferson, Lawrence,
McKean, Mercer, and Venango.

1300-PM-BIT0001 5/2012
Form
Page 1 of 7
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
GENERAL INFORMATION FORM – AUTHORIZATION APPLICATION
Before completing this General Information Form (GIF), read the step-by-step instructions provided in this application package.
This version of the General Information Form (GIF) must be completed and returned with any program-specific application being
submitted to the Department.
Related ID#s (If Known)
DEP USE ONLY
Client ID#
APS ID#
Date Received & General Notes
Site ID#
Auth ID#
Facility ID#
CLIENT INFORMATION
DEP Client ID#
Client Type / Code
Organization Name or Registered Fictitious Name
Employer ID#
(EIN)
Dun & Bradstreet ID#
Individual Last Name
First Name
MI
Suffix
SSN
Additional Individual Last Name
First Name
MI
Suffix
SSN
Mailing Address Line 1
Mailing Address Line 2
Address Last Line – City
State
ZIP+4
Country
Client Contact Last Name
First Name
MI
Suffix
Client Contact Title
Phone
Ext
Email Address
FAX
SITE INFORMATION
DEP Site ID#
Site Name
EPA ID#
Estimated Number of Employees to be Present at Site
Description of Site
County Name
Municipality
City
Boro
Twp
State
County Name
Municipality
City
Boro
Twp
State
Site Location Line 1
Site Location Line 2
Site Location Last Line – City
State
ZIP+4
Detailed Written Directions to Site
Site Contact Last Name
First Name
MI
Suffix
Site Contact Title
Site Contact Firm
Mailing Address Line 1
Mailing Address Line 2
Mailing Address Last Line – City
State
ZIP+4

1300-PM-BIT0001
5/2012
Page 2 of 7
Phone
Ext
FAX
Email Address
NAICS Codes
(Two- & Three-Digit Codes – List All That Apply)
6-Digit Code
(Optional)
Client to Site Relationship
FACILITY INFORMATION
Modification of Existing Facility
Yes
No
1.
Will this project modify an existing facility, system, or activity?
2.
Will this project involve an addition to an existing facility, system, or activity?
If “Yes”, check all relevant facility types and provide DEP facility identification numbers below.
Facility Type
DEP Fac ID#
Facility Type
DEP Fac ID#
Air Emission Plant
Industrial Minerals Mining Operation
Beneficial Use (water)
Laboratory Location
Blasting Operation
Land Recycling Cleanup Location
Captive Hazardous Waste Operation
MineDrainageTrmt/LandRecyProjLocation
Coal Ash Beneficial Use Operation
Municipal Waste Operation
Coal Mining Operation
Oil & Gas Encroachment Location
Coal Pillar Location
Oil & Gas Location
Commercial Hazardous Waste Operation
Oil & Gas Water Poll Control Facility
Dam Location
Public Water Supply System
Deep Mine Safety Operation -Anthracite
Radiation Facility
Deep Mine Safety Operation -Bituminous
Residual Waste Operation
Deep Mine Safety Operation -Ind Minerals
Storage Tank Location
Encroachment Location (water, wetland)
Water Pollution Control Facility
Erosion & Sediment Control Facility
Water Resource
Explosive Storage Location
Other:
Latitude/Longitude
Latitude
Longitude
Point of Origin
Degrees
Minutes
Seconds
Degrees
Minutes
Seconds
Horizontal Accuracy Measure
Feet
--or--
Meters
Horizontal Reference Datum Code
North American Datum of 1927
North American Datum of 1983
World Geodetic System of 1984
Horizontal Collection Method Code
Reference Point Code
Altitude
Feet
--or--
Meters
Altitude Datum Name
The National Geodetic Vertical Datum of 1929
The North American Vertical Datum of 1988 (NAVD88)
Altitude (Vertical) Location Datum Collection Method Code
Geometric Type Code
Data Collection Date
Source Map Scale Number
Inch(es)
=
Feet
--or--
Centimeter(s)
=
Meters
PROJECT INFORMATION
Project Name
Project Description
Project Consultant Last Name
First Name
MI
Suffix
Project Consultant Title
Consulting Firm
Mailing Address Line 1
Mailing Address Line 2
Address Last Line – City
State
ZIP+4

1300-PM-BIT0001
5/2012
Page 3 of 7
Phone
Ext
FAX
Email Address
Time Schedules
Project Milestone (Optional)
1. Have you informed the surrounding community and addressed any
concerns prior to submitting the application to the Department?
Yes
No
2.
Is your project funded by state or federal grants?
Yes
No
Note:
If “Yes”, specify what aspect of the project is related to the grant and provide the grant source, contact person
and grant expiration date.
Aspect of Project Related to Grant
Grant Source:
Grant Contact Person:
Grant Expiration Date:
3.
Is this application for an authorization on Appendix A of the Land Use
Policy? (For referenced list, see Appendix A of the Land Use Policy
attached to GIF instructions)
Yes
No
Note:
If “No” to Question 3, the application is not subject to the Land Use Policy.
If “Yes” to Question 3, the application is subject to this policy and the Applicant should answer the additional
questions in the
Land Use Information
section.
LAND USE INFORMATION
Note:
Applicants are encouraged to submit copies of local land use approvals or other evidence of compliance with
local comprehensive plans and zoning ordinances.
1.
Is there an adopted county or multi-county comprehensive plan?
Yes
No
2.
Is there an adopted municipal or multi-municipal comprehensive plan?
Yes
No
3. Is there an adopted county-wide zoning ordinance, municipal zoning
ordinance or joint municipal zoning ordinance?
Yes
No
Note:
If the Applicant answers “No” to either Questions 1, 2 or 3, the provisions of the PA MPC are not applicable and
the Applicant does not need to respond to questions 4 and 5 below.
If the Applicant answers “Yes” to questions 1, 2 and 3, the Applicant should respond to questions 4 and 5 below.
4.
Does the proposed project meet the provisions of the zoning ordinance or
does the proposed project have zoning approval?
If zoning approval has been
received, attach documentation.
Yes
No
5.
Have you attached Municipal and County Land Use Letters for the project?
Yes
No

1300-PM-BIT0001
5/2012
Page 4 of 7
COORDINATION INFORMATION
Note:
The PA Historical and Museum Commission must be notified of proposed projects in accordance with DEP
Technical Guidance Document 012-0700-001 and the accompanying Cultural Resource Notice Form.
If the activity will be a mining project
(i.e., mining of coal or industrial minerals, coal refuse disposal and/or the
operation of a coal or industrial minerals preparation/processing facility), respond to questions 1.0 through 2.5
below.
If the activity will not be a mining project
, skip questions 1.0 through 2.5 and begin with question 3.0.
1.0
Is this a coal mining project?
If “Yes”, respond to 1.1-1.6. If “No”, skip to
Question 2.0.
Yes
No
1.1 Will this coal mining project involve coal preparation/ processing
activities in which the total amount of coal prepared/processed will be
equal to or greater than 200 tons/day?
Yes
No
1.2 Will this coal mining project involve coal preparation/ processing
activities in which the total amount of coal prepared/processed will be
greater than 50,000 tons/year?
Yes
No
1.3 Will this coal mining project involve coal preparation/ processing
activities in which thermal coal dryers or pneumatic coal cleaners will be
used?
Yes
No
1.4 For this coal mining project, will sewage treatment facilities be
constructed and treated waste water discharged to surface waters?
Yes
No
1.5
Will this coal mining project involve the construction of a permanent
impoundment meeting one or more of the following criteria: (1) a
contributory drainage area exceeding 100 acres; (2) a depth of water
measured by the upstream toe of the dam at maximum storage elevation
exceeding 15 feet; (3)
an impounding capacity at maximum storage
elevation exceeding 50 acre-feet?
Yes
No
1.6
Will this coal mining project involve underground coal mining to be
conducted within 500 feet of an oil or gas well?
Yes
No
2.0
Is this a non-coal (industrial minerals) mining project?
If “Yes”, respond to
2.1-2.6. If “No”, skip to Question 3.0.
Yes
No
2.1 Will this non-coal (industrial minerals) mining project involve the
crushing and screening of non-coal minerals other than sand and
gravel?
Yes
No
2.2 Will this non-coal (industrial minerals) mining project involve the
crushing and/or screening of sand and gravel with the exception of wet
sand and gravel operations (screening only) and dry sand and gravel
operations with a capacity of less than 150 tons/hour of unconsolidated
materials?
Yes
No
2.3 Will this non-coal (industrial minerals) mining project involve the
construction, operation and/or modification of a portable non-metallic
(i.e., non-coal)
minerals processing plant under the authority of the
General Permit for Portable Non-metallic Mineral Processing Plants (i.e.,
BAQ-PGPA/GP-3)?
Yes
No
2.4 For this non-coal (industrial minerals) mining project, will sewage
treatment facilities be constructed and treated waste water discharged to
surface waters?
Yes
No
2.5 Will this non-coal (industrial minerals) mining project involve the
construction of a permanent impoundment meeting one or more of the
following criteria: (1) a contributory drainage area exceeding 100 acres;
(2)
a depth of water measured by the upstream toe of the dam at
maximum storage elevation exceeding 15 feet; (3) an impounding
capacity at maximum storage elevation exceeding 50 acre-feet?
Yes
No

1300-PM-BIT0001
5/2012
Page 5 of 7
3.0
Will your project, activity, or authorization have anything to do with a
well related to oil or gas production, have construction within 200 feet of,
affect an oil or gas well, involve the waste from such a well, or string
power lines above an oil or gas well?
If “Yes”, respond to 3.1-3.3. If “No”,
skip to Question 4.0.
Yes
No
3.1 Does the oil- or gas-related project involve any of the following:
placement of fill, excavation within or placement of a structure, located
in, along, across or projecting into a watercourse, floodway or body of
water (including wetlands)?
Yes
No
3.2 Will the oil- or gas-related project involve discharge of industrial
wastewater or stormwater to a dry swale, surface water, ground water or
an existing sanitary sewer system or storm water system?
If “Yes”,
discuss in
Project Description
.
Yes
No
3.3
Will the oil- or gas-related project involve the construction and operation
of industrial waste treatment facilities?
Yes
No
4.0
Will the project involve a construction activity that results in earth
disturbance?
If “Yes”, specify the total disturbed acreage.
Yes
No
4.0.1
Total Disturbed Acreage
5.0
Does the project involve any of the following?
If “Yes”, respond to 5.1-5.3. If “No”, skip to Question 6.0.
Yes
No
5.1 Water Obstruction and Encroachment Projects – Does the project
involve any of the following: placement of fill, excavation within or
placement of a structure, located in, along, across or projecting into a
watercourse, floodway or body of water?
Yes
No
5.2 Wetland Impacts – Does the project involve any of the following:
placement of fill, excavation within or placement of a structure, located
in, along, across or projecting into a wetland?
Yes
No
5.3
Floodplain Projects by the commonwealth, a Political Subdivision of the
commonwealth or a Public Utility – Does the project involve any of the
following: placement of fill, excavation within or placement of a
structure, located in, along, across or projecting into a floodplain?
Yes
No
6.0
Will the project involve discharge of stormwater or wastewater from an
industrial activity to a dry swale, surface water, ground water or an
existing sanitary sewer system or separate storm water system?
Yes
No
7.0
Will the project involve the construction and operation of industrial
waste treatment facilities?
Yes
No
8.0 Will the project involve construction of sewage treatment facilities,
sanitary sewers, or sewage pumping stations?
If “Yes”, indicate estimated
proposed flow (gal/day). Also, discuss the sanitary sewer pipe sizes and the
number of pumping stations/treatment facilities/name of downstream sewage
facilities in the
Project Description
, where applicable.
Yes
No
8.0.1
Estimated Proposed Flow (gal/day)
9.0
Will the project involve the subdivision of land, or the generation of 800
gpd or more of sewage on an existing parcel of land or the generation of
an additional 400 gpd of sewage on an already-developed parcel, or the
generation of 800 gpd or more of industrial wastewater that would be
discharged to an existing sanitary sewer system?
Yes
No
9.0.1
Was Act 537 sewage facilities planning submitted and
approved by DEP?
If “Yes” attach the approval letter. Approval
required prior to 105/NPDES approval.
Yes
No
10.0 Is this project for the beneficial use of biosolids for land application
within Pennsylvania?
If “Yes” indicate how much (i.e. gallons or dry tons per
year).
Yes
No
10.0.1
Gallons Per Year (residential septage)
10.0.2
Dry Tons Per Year (biosolids)
11.0
Does the project involve construction, modification or removal of a dam?
If “Yes”, identify the dam.
Yes
No
11.0.1
Dam Name

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Page 6 of 7
12.0
Will the project interfere with the flow from, or otherwise impact, a dam?
If “Yes”, identify the dam.
Yes
No
12.0.1
Dam Name
13.0
Will the project involve operations (excluding during the construction
period) that produce air emissions (i.e., NOX, VOC, etc.)?
If “Yes”, identify
each type of emission followed by the amount of that emission.
Yes
No
13.0.1
Enter all types & amounts
of emissions; separate
each set with semicolons.
14.0
Does the project include the construction or modification of a drinking
water supply to serve 15 or more connections or 25 or more people, at
least 60 days out of the year?
If “Yes”, check all proposed sub-facilities.
Yes
No
14.0.1
Number of Persons Served
14.0.2
Number of Employee/Guests
14.0.3
Number of Connections
14.0.4
Sub-Fac: Distribution System
Yes
No
14.0.5
Sub-Fac: Water Treatment Plant
Yes
No
14.0.6
Sub-Fac: Source
Yes
No
14.0.7
Sub-Fac: Pump Station
Yes
No
14.0.8
Sub Fac: Transmission Main
Yes
No
14.0.9
Sub-Fac: Storage Facility
Yes
No
15.0
Will your project include infiltration of storm water or waste water to
ground water within one-half mile of a public water supply well, spring or
infiltration gallery?
Yes
No
16.0
Is your project to be served by an existing public water supply?
If “Yes”,
indicate name of supplier and attach letter from supplier stating that it will
serve the project.
Yes
No
16.0.1
Supplier’s Name
16.0.2
Letter of Approval from Supplier is Attached
Yes
No
17.0
Will this project involve a new or increased drinking water withdrawal
from a stream or other water body?
If “Yes”, should reference both Water
Supply and Watershed Management.
Yes
No
17.0.1
Stream Name
18.0 Will the construction or operation of this project involve treatment,
storage, reuse, or disposal of waste?
If “Yes”, indicate what type (i.e.,
hazardous, municipal (including infectious & chemotherapeutic), residual) and
the amount to be treated, stored, re-used or disposed.
Yes
No
18.0.1
Type & Amount
19.0
Will your project involve the removal of coal, minerals, etc. as part of any
earth disturbance activities?
Yes
No
20.0
Does your project involve installation of a field constructed underground
storage tank?
If “Yes”, list each Substance & its Capacity.
Note:
Applicant
may need a Storage Tank Site Specific Installation Permit.
Yes
No
20.0.1 Enter all substances &
capacity of each; separate
each set with semicolons.
21.0
Does your project involve installation of an aboveground storage tank
greater than 21,000 gallons capacity at an existing facility?
If “Yes”, list
each Substance & its Capacity.
Note:
Applicant may need a Storage Tank
Site Specific Installation Permit.
Yes
No
21.0.1 Enter all substances &
capacity of each; separate
each set with semicolons.

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22.0
Does your project involve installation of a tank greater than 1,100 gallons
which will contain a highly hazardous substance as defined in DEP’s
Regulated Substances List, 2570-BK-DEP2724?
If “Yes”, list each
Substance & its Capacity.
Note:
Applicant may need a Storage Tank Site
Specific Installation Permit.
Yes
No
22.0.1 Enter all substances &
capacity of each; separate
each set with semicolons.
23.0
Does your project involve installation of a storage tank at a new facility
with a total AST capacity greater than 21,000 gallons?
If “Yes”, list each
Substance & its Capacity.
Note:
Applicant may need a Storage Tank Site
Specific Installation Permit.
Yes
No
23.0.1 Enter all substances &
capacity of each; separate
each set with semicolons.
24.0
Will the intended activity involve the use of a radiation source?
Yes
No
CERTIFICATION
I certify that I have the authority to submit this application on behalf of the applicant named herein and
that the information provided in this application is true and correct to the best of my knowledge and
information.
Type or Print Name
Signature
Title
Date

1300-PM-BIT0001
5/2012
Checklist
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
GENERAL INFORMATION FORM -- AUTHORIZATION APPLICATION
APPLICANT’S CHECKLIST
This final checklist is to assist the applicant in assuring that all requests for responses, contacts, additional
documentation, etc. have been addressed. Please check the following list to make sure that you have included all the
required information. Failure to provide all of the requested information will delay the processing of the application and
may result in the application being placed on hold with no action, or will be considered withdrawn and the application file
closed. This applicant’s checklist need not be returned to DEP with your completed application.
REQUIREMENTS
1. ATTACHMENTS.
The completion of the GIF may require the submission of some or all of the following.
Where appropriate, include the appropriate attachment(s) with the completed GIF.
a) Site Information, Written Directions to Site
- Attach additional sheets as necessary.
b) Facility Information, Latitude/Longitude
– Attach additional sheets as necessary.
c) Project Information, Project Description
– Attach additional sheets as necessary.
d) Project Information, Time Schedules
-- Attach additional sheets as necessary.
e) Land Use Information
– Please attached completed County and Municipal Land Use Letters. If County
and Municipal Land Use Letters are not included, please attach documentation indicating zoning approval (for
early opt-out option), or certified mail receipts indicating that requests for County and Municipal Land Use
Letters were sent to the county and municipality. For more information, see GIF Instructions
and the
Department's Policy for Consideration of Local Comprehensive Plans and Zoning Ordinances in DEP Review of
Authorizations for Facilities and Infrastructure - Document ID: 012-0200-001.
f) Coordination Information
- If land is disturbed, it may be the applicant’s responsibility to also notify the PA
Historical and Museum Commission, Bureau of Historic Preservation, 400 North Street, Floor 2, Harrisburg,
PA 17120-0093, (717) 787-3362.
PHMC notification is required for:
1) purposes of construction activities for Individual NPDES permits disturbing 10 or more acres; and
2) Erosion & Sediment Control permits.
General NPDES permits disturbing 10 or more acres are exempt from PHMC notification. For additional
information, see Cultural Resource Notice instructions to determine whether submission of information to
PHMC is required for this permit application.
g) Coordination Information, Question 9.0.1
– Attach copy– Act 537 Approval Letter. Note: Approval
required prior to 105/NPDES approval.
h) Coordination Information, Question 16.0.2
– Attach copy - Public Water Supplier’s Agreement Letter to
Serve the Project.
2.
CONTACTS MADE.
According to information provided in the Coordination Information section, the appropriate
DEP office may need to be contacted; as well as some agencies outside DEP. See the Instructions document
for appropriate contact per coordination question.
In addition to contacts referenced above, prior to proceeding with any project, DEP encourages applicants to be
in touch with municipal and county governments to get information on and secure, if possible, any local permits
or approvals that might be required for the project. By doing so, potential conflicts at the local level can be
resolved prior to application submission to DEP.
3.
BEFORE YOU DIG -- CONTACT.
Pennsylvania One Call System at 1-800-242-1776.
4. APPLICATION SUBMITTED.
Application has been completed and properly signed according to instructions
and type codes; and will be submitted to the appropriate DEP office.

1300-PM-BIT0001
5/2012
GIF Codes
Page 1 of 4
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
GENERAL INFORMATION FORM -- AUTHORIZATION APPLICATION
LOCATIONAL DATA CODES
GENERAL INFORMATION
Locational data information aids the Department in determining the method, accuracy
and description of the latitude and longitude information that is being provided with the
application.
LOCATIONAL DATA CODES
Horizontal Accuracy Measure.
The measure of the accuracy in feet of the latitude and longitude
coordinates. Using the latitude and longitude
coordinates provided by the applicant will guarantee you
are no more than this number of feet or meters from the actual location.
Horizontal Reference Datum.
The code and description that represent the reference datum used in
determining latitude and longitude coordinates.
Horizontal Collection Method.
The code and description that represent the method used to determine
the latitude and longitude coordinates for a point on the earth.
Code
Description
EMAP
Geographic coordinate determination method is based on eMapPA.
HGIS
Geographic coordinate determination method based on DCNR’s Heritage database (PNDI).
LOCAT
Geographic coordinate determination based on PADEP Lat Long Locator tool.
NPWEB
NPSBMP Input Website
NTDEP
Locational data submitted by applicant or other source outside of DEP
RNDRP
Raindrop Tool
WAAS
Geographic coordinate determination method based on GPS WAAS differentially corrected.
ZP2CN
Center of an area defined by the 5-digit ZIP code and its 2-digit geographic segment
extension.
ZP4CN
Center of an area defined by the 5-digit ZIP code and its 4-digit geographic segment
extension.
EPGPS
Environmental Protection GPS Equipment
AMBLF
Geographic coordinate determination method based on address matching-block face.
AMDIG
Geographic coordinate determination method based on address matching-digitized.
AMHNO
Geographic coordinate determination method based on address matching-house number.
AMINT Geographic coordinate determination method based on address matching-nearest
intersection
AMOTH
Geographic coordinate determination method based on address matching-other.
AMPN
Geographic coordinate determination method based on address matching-primary name.
AMSTC
Geographic coordinate determination method based on address matching-street centerline.
CB90
Geographic coordinate determination method based on census block-1990-centroid.
CB90G
Geographic coordinate determination method based on census/group-1990-centroid.
CB90T
Geographic coordinate determination method based on census/tract-1990-centroid.
CENOT
Geographic coordinate determination method based on census-other.
SURVY
Geographic coordinate determination method based on classical surveying techniques.
GPSKN
Geographic coordinate determination method based on GPS carrier phase kinematic relative
positioning technique.

1300-PM-BIT0001
5/2012
GIF Codes
Page 2 of 4
Code
Description
GPSST
Geographic coordinate determination method based on GPS carrier phase static relative
positioning technique.
GPSDF
Geographic coordinate determination method based on GPS code measurements (pseudo
range) differential (DGPS).
GPSPR
Geographic coordinate determination method based on GPS code measurements (pseudo
range) precise positioning service.
GPSON
Geographic coordinate determination method based on GPS code measurements (pseudo
range) standard positioning service (SA On).
GPSOF
Geographic coordinate determination method based on GPS code measurements (pseudo
range) standard positioning service (SA Off).
ITPMP
Geographic coordinate determination method based on interpolation-map.
ITPOT
Geographic coordinate determination method based on interpolation-other.
ITPPH
Geographic coordinate determination method based on interpolation-photo.
ITPSA
Geographic coordinate determination method based on interpolation-satellite.
LORAN
Geographic coordinate determination method based on Loran C.
PLSQS
Geographic coordinate determination method based on public land survey quarter of a
section.
PLSSC
Geographic coordinate determination method based on public land survey section.
GISDR
Geographic coordinate determination method based on the use of GIS and Digital Raster
Graphic 1:24000 scale USGS 7.5 minute quadrangle maps.
ZPCEN
Geographic coordinate determination method based on zipcode-centroid.
TIGER
Geographic coordinate determination method is based on a digital map source (TIGER).
PLSES
Geographic coordinate determination method is based on a public land survey, an eighth of
a section.
PLSFT
Geographic coordinate determination method is based on a public land survey footing.
PLSSX
Geographic coordinate determination method is based on a public land survey, a sixteenth of
a section.
ITPMS
Geographic coordinate determination method is based on the use of a Multi-Spectral
Scanner (MSS).
ITPTM
Geographic coordinate determination method is based on the use of a Thematic Mapper
(TM).
ITPSP Geographic coordinate determination method uses SPOT (Systeme Probatoire
d'Observation de la Terre), a French-owned satellite launched in 1984.
GPS
Global Positioning Method, with unspecified parameters.
GPSCN
GPS Code Measurements (pseudo range) Standard Positioning Service Corrected using
Canadian Active Control System.
UNK
Unknown
Reference Point Code.
The code and description that represent the place for which geographic
coordinates were established.
Code
Description
CNTAR
Center of Area
DISPT
Primary discharge point for a body of water whether natural or manmade.
INTC
Interconnection – A point of connection between facilities NPSBP NPSBMP Location.
NPSBP
NPSBMP Location
PSBS
Point on streambank or shoreline.
UPSB
Upstream point on bank or shoreline
WAPPS
Water Allocation Permit Primary Source – The water allocation permit location references
the primary source point covered under the permit.
ADBLD
Administrative Building-A building where business, school, or governmental business affairs
are managed.
AIRMN
Air Monitoring Station-The station where air monitoring occurs.

1300-PM-BIT0001
5/2012
GIF Codes
Page 3 of 4
Code
Description
AIRST
Air Release Stack-The stack where air releases occur.
AIRVT
Air Release Vent-The vent where air releases occur.
ATETU
Atmospheric Emissions Treatment Unit-The unit where atmospheric emissions are treated.
CNTER
Center of the facility.
CTROD
Centroid for the area where the facility is.
INPIP
Intake Pipe-A pipe where fluid enters an enclosure.
LGOON
Lagoon or Settling Pond-A body of water at rest, where clarification takes place as sediment
is deposited.
LWTU
Liquid Waste Treatment Unit-The unit where liquid waste is treated.
LODCT
Loading Area Centroid-The centroid for the loading area.
LODNG
Loading Facility-The facility where loading occurs.
CORNE
Northeast corner of the land parcel.
CORNW
Northwest corner of the land parcel.
WELOG
Oil or Gas Well
ENTFT
Plant Entrance (freight)-The freight entrance to a plant.
ENTGN
Plant Entrance (general)-The general entrance to a plant.
ENTPE
Plant Entrance (personnel)-The personnel entrance to a plant.
CNTAM
Potential source of contamination to drinking water supply.
PUCEN
Process Unit Area Centroid-The centroid for the area where the process unit is.
PUNIT
Process Unit-The unit where processing occurs.
SWSTR
Solid Waste Storage Area-The area where solid wastes are stored.
SWTDU
Solid Waste Treatment/Disposal Unit-The unit where solid wastes are treated or disposed of.
H2OSR
Source Water Area-The area that potentially supplies water to a drinking water intake.
H2OPR Source Water Protection Area-The drinking water source area where protective
management action occur.
CORSE
Southeast corner of the land parcel.
CORSW
Southwest corner of the land parcel.
SPRNG
Spring-A place where ground water flows naturally from a rock or the soil into the land
surface or into a body of surface water.
STANK
Storage Tank
UNK
Unknown-The information is not known.
H2OMS
Water Monitoring Station-The station where water monitoring occurs.
H2OPI
Water Release Pipe-The pipe where water releases occur.
H2OWL
Water Well-A shaft or dug hole, whose depth is greater than its diameter, sunk into the
ground to a depth that allows the withdrawal of water from a water-yielding geologic unit.
WELPA
Wellhead Protection Area-The surface and subsurface area surrounding a water well or well
field, supplying a public water system, through which contaminants are reasonably likely to
move toward and reach such water well or well field.
Altitude.
The height of anything above a given planetary reference plane. In this document, altitude
should be referenced to sea level on earth.
Altitude Datum Name.
The identification given to the surface taken as the surface of reference from
which altitudes are measured.
Altitude (Vertical) Location Datum Collection Method.
The code and description that represent the
method used to collect the vertical measure (i.e., the altitude) of a reference point.
Code
Description
UNK
Unknown
ALTIM
A method used to determine vertical components based on altimetry.
SRVEY
Geographic coordinate determination method based on classical surveying techniques.

1300-PM-BIT0001
5/2012
GIF Codes
Page 4 of 4
Code
Description
GPSKN
Geographic coordinate determination method based on GPS carrier phase kinematic relative
positioning technique.
GPSST
Geographic coordinate determination method based on GPS carrier phase static relative
positioning technique.
GPSDF
Geographic coordinate determination method based on GPS code measurements (pseudo
range) differential (DGPS).
GPSPR
Geographic coordinate determination method based on GPS code measurements (pseudo
range) precise positioning service.
GPSOF
Geographic coordinate determination method based on GPS code measurements (pseudo
range) standard positioning service (SA Off).
GPSON
Geographic coordinate determination method based on GPS code measurements (pseudo
range) standard positioning service (SA On).
LVLNB
Leveling between non-benchmark control points.
PHGRM
Photogrammetric.
LVLBM
Precise leveling from a bench mark.
TOPO
Topographic map interpolation.
TRGLV
Trigonometric leveling.
Geometric Type Code.
The code and description that represent the geometric entity represented by one
point or a sequence of latitude and longitude points.
Code
Description
POINT
Point referenced by geographic coordinates.
Data Collection Date.
The calendar date when data were collected.
Source Map Scale Number.
The number that represents the proportional distance on the ground for one
unit of measure on the map or photo. An example of this type of information is 1 inch = 10 feet.

8000-PM-IT0001
Rev 8/2009
APX
APPENDIX A
AUTHORIZATION/APPLICATION TYPES AFFECTED BY DEP’S LAND USE POLICY
The following authorization types are affected by DEP’s Land Use Policy. The last column is for
crosswalk to DEP’s
e
FACTS data system codes and is added for DEP staff reference or for electronic
authorization application submissions.
AIR QUALITY PROGRAM
Authorization/Permit Type & Description
(Applies only to air quality permit applications that are
outside of an existing
permitted area
)
e
FACTS Codes
Major Facility Plan Approval -
Case-by-Case MACT
MASAT/NEW
Hazardous Air Pollutant Standard Part 61
MFAP/NEW
MACT Air Toxics Part 63
MAAT/NEW
New Facility Review Prevention of Significant Deterioration
MNSRP/NEW
New Source Performance Standard
MFSP/NEW
New Source Review Non-Attainment
MNSRN/NEW
State Regulation
MFSR/NEW
Minor Facility Plan Approval -
Hazardous Air Pollutant Standard Part 61
MISAT/NEW
MACT Air Toxics
MSATM/NEW
New Source Performance Standard
MISPS/NEW
State Regulation
MSSR/NEW
COAL MINING PROGRAM
Authorization/Permit Type & Description
e
FACTS Codes
Preparation-Processing Plant Permit
P/NEW
Refuse Disposal Permit
RD/NEW
Surface Mining Permit
SM/NEW
Underground Mining Permit (surface facilities only)
UM/NEW
INDUSTRIAL MINERALS (NONCOAL) MINING PROGRAM
Authorization/Permit Type & Description
e
FACTS Codes
Large Surface Mining Permit (includes underground mining, surface facilities)
LSM/NEW
Small Surface Mining Permit (includes bluestone surface mining)
NSM/NEW
OIL & GAS MANAGEMENT PROGRAM
Authorization/Permit Type & Description
e
FACTS Codes
Drilling or Altering a Well (Disposal Wells Only)
DOWDR/NEW
Water Obstruction & Encroachment Permit
8WOJP/NEW
Centralized Impoundment Dam Permit
DAMOG/NEW
Water Quality Mgmt Part II, Industrial Wastewater Facility
8W2IW/NEW
Page 1 of 3

8000-PM-IT0001
Rev 8/2009
WASTE MANAGEMENT – HAZARDOUS WASTE PROGRAM
Authorization/Permit Type & Description
e
FACTS Codes
Captive Disposal Permit
CD/NEW
Captive Storage Permit
CS/NEW
Captive Treatment Permit
CT/NEW
Commercial Disposal Permit
COD/NEW *
Commercial Recycling Permit
COR/NEW
Commercial Storage Permit
COS/NEW
Commercial Treatment Permit
COT/NEW *
WASTE MANAGEMENT – MUNICIPAL WASTE PROGRAM
Authorization/Permit Type & Description
e
FACTS Codes
Construction/Demolition Landfill Permit (Alternative Project)
(new facility)
CDLA/NEW *
Expansion of Increased Capacity/Acreage
CDL/MODEO *
Municipal Waste Landfill
(new facility)
LA/NEW *
Expansion of Increased Capacity/Acreage
L/MODEO *
MW Composting Permit
C/NEW
Resource Recovery & Other Processing Permit
RRO/NEW
Transfer Facility Permit
TS/NEW
WASTE MANAGEMENT – RESIDUAL WASTE PROGRAM
Authorization/Permit Type & Description
e
FACTS Codes
Residual Waste Landfill-Class I, II or III Permit (commercial or captive)
(new facility)
RL3A/NEW
Expansion of Increased Capacity/Acreage
RL3/MOD
Commercial Landfill-Class I, II or III Permit (Alternative Project)
(new facility)
RL3AP/NEW *
Expansion of Increased Capacity/Acreage
RL3AP/MOD *
Disposal Impoundment-Class I or II Permit
DI2/NEW *
Processing and/or Incinerator Permit
PI/NEW
RW Composting Permit
RC/NEW
Transfer Facility Permit
T/NEW
WASTE MANAGEMENT – STORAGE TANKS PROGRAM
Authorization/Permit Type & Description
(Applies only to site-specific installation permit applications that are
outside of an existing permitted
area
)
Authorization/Permit Type & Description
e
FACTS Codes
Site-Specific Installation Permit
SSIP/NEW
Page 2 of 3

8000-PM-IT0001
Rev 8/2009
Page 3 of 3
RADIATION PROTECTION PROGRAM
Authorization/Permit Type & Description
e
FACTS Codes
Waste Storage Processing and Disposal
RP/NEW
Waste Packaging or Repackaging
RP/NEW
Nuclear Laundry
RP/NEW
Irradiator Requirements
RP/NEW
WATER MANAGEMENT – DAM SAFETY PROGRAM
Authorization/Permit Type & Description
e
FACTS Codes
Dam Safety Permit
DSP/NEW
Limited Power Permit
LPP/NEW
WATER MANAGEMENT – NPDES PROGRAM
Authorization/Permit Type & Description
e
FACTS Codes
Concentrated Animal Feeding Operations Individual NPDES Permit
NCAF/NEW
NPDES Pmt for Sewage Discharges Municipal, Major
NSMMA/NEW
NPDES Pmt for New & Existing Sewage Discharger, Municipal, Minor
NSMMI/NEW
NPDES Pmt Sewage Discharge Non-Municipal-Major
NSNMA/NEW
NPDES Pmt Sewage Discharges Non-Municipal-Minor
NSNMI/NEW
NPDES Permit for New & Existing Industrial Discharger, Major
NIWMA/NEW
NPDES Permit Industrial Wastewater Discharge Minor
NIWM/NEW
NPDES Permit Stormwater Industrial Site Runoff
NSIR/NEW
WATER MANAGEMENT – STATE WATER POLLUTION CONTROL PROGRAM
Authorization/Permit Type & Description
e
FACTS Codes
Water Quality Mgmt Part II, Industrial Wastewater Facility
W2IW/NEW
Water Quality Mgmt Part II, Manure Storage Facility for CAFO
W2CAF/NEW
WATER SUPPLY MANAGEMENT – SAFE DRINKING WATER PROGRAM
Authorization/Permit Type & Description
e
FACTS Codes
Public Water Supply Permit Bottled Water System Construction
BWSC/NEW
Public Water Supply Permit Bottled Water System-Finished Water Source
Construction BWSFC/NEW
Public Water Supply Permit Bulk Water Hauler-Finished Water Source Construction BWHF/NEW
Public Water Supply Permit Bulk Water Hauler Construction
BWHC/NEW
Public Water Supply Permit Community Water System Construction
CWSC/NEW
Public Water Supply Permit Retail Water System Construction
RWSC/NEW
Public Water Supply Permit Retail Water System-Finished Water Source Construction
RWSFW/NEW
Public Water Supply Permit Vended Water System Construction
VWSC/NEW
WATERSHED MANAGEMENT – EROSION & SEDIMENT PROGRAM
Authorization/Permit Type & Description
e
FACTS Codes
Erosion & Sediment Control Permit
EDP/NEW
NPDES Permit Stormwater-Construction
NSC/NEW
PAG-02 NPDES Stormwater-Construction (general permit; includes all PAG-02s
except those required for Oil & Gas activities)
NSC2/NEW
WATERSHED MANAGEMENT – WATER OBSTRUCTION & ENCROACHMENT PROGRAM
Authorization/Permit Type & Description
e
FACTS Codes
Water Obstruction & Encroachment Permit
WOJP/NEW
* If a different project timeline is negotiated, a special
e
FACTS code will be established.

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
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- 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

0120-PM-PY0003 Rev. 5/2006
COMMONWEALTH OF PENNSYLVANIA
INSTRUCTIONS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
INSTRUCTIONS FOR COMPLETING
CULTURAL RESOURCE NOTICE
- 1 -
GENERAL INFORMATION
This package is designed to assist the applicant in completing the
necessary documentation regarding archaeological sites and historic
structures encountered while undertaking permitting projects.
This form is to be completed, signed, and dated by applicants for
certain DEP permits or plan approvals. Please refer to the List of
Exemptions for a list of applications which are exempt from this
requirement. It is the responsibility of the applicant to complete this
form and mail it to the PHMC at the following address:
Pennsylvania Historical and Museum Commission
Bureau of Historic Preservation
400 North Street, Second Floor
Harrisburg, PA 17120-0093
Please be aware that PHMC will keep the Notice and submitted
materials for its files. Therefore, keep a copy of the Notice and any
materials submitted with it. Applicants should mail all Cultural
Resource Notices “Certified Mail Return Receipt Requested” in order to
prove submission and the date PHMC received the Notice.
Attach a copy of your completed Cultural Resource Notice and the
return receipt to your permit application.
SECTION A. APPLICANT IDENTIFIER
For purposes of identifying and tracking complete permit packages,
enter the following requested information.
APPLICANT NAME.
Please insert applicant name using the same
name as will be used with the Permit Application. Also, please insert
applicant address and phone number. (Note: This would not
be the
consultant or engineering firm preparing the application.)
PROJECT TITLE.
Please enter the title of the project as will be used
with the Permit Application.
SECTION B. LOCATION OF PROJECT
MUNICIPALITY.
Indicate the municipality(ies) in which the site is
located. If the site is located in more than two municipalities, attach a
separate sheet of paper.
COUNTY.
Indicate the county(ies) in which the site is located. Write
out the county name and also give the DEP county code. (County
codes are provided on page 2 of these instructions.) If the site is
located in more than two counties, attach a separate sheet of paper.
SECTION C. PERMITS OR APPROVALS
Give the name(s) of specific DEP permit or approval. Check the
appropriate box for any anticipated federal permits that may be
required.
SECTION D. GOVERNMENT FUNDING
SOURCES
Indicate any authorized or anticipated governmental funding source
and give the name of this funding source, i.e., PennVest or Rural Utility
Services.
SECTION E. RESPONSIBLE DEP REGIONAL,
CENTRAL, DISTRICT MINING, OR OIL AND GAS
MANAGEMENT OFFICE
Check the appropriate box that identifies the DEP Regional, Central,
District Mining, or Oil and Gas Management Office that is responsible
for the review of this permit application. A list of DEP offices and
counties supported is included at the end of these instructions.
SECTION F. COUNTY CONSERVATION
DISTRICT
Some permit applications are reviewed by County Conservation
Districts. If this is the case, give the name of the district office and the
telephone number, if known.
SECTION G. CONSULTANT IDENTIFIER
For purposes of avoiding confusion should the consultant submit the
determination notice to PHMC for the applicant, enter the following
requested information: Consultant Engineer Name, Address and
Telephone Number.
SECTION H. PROJECT BOUNDARIES AND
DESCRIPTION
Assure that the following items are attached and submitted with the
Notice form:
• 7.5' USGS Map indicating boundaries of the proposed activity.
Maps should include all relevant details. (Example: For a sewage
facilities plan, the location of proposed sewerage facilities, including
collection sewers, interceptor lines, pump stations and sewage
treatment plants would be relevant information that PHMC would
need.)
• Narrative description of the proposed activity.
• Photographs of any buildings over 50 years old. Indicate what is to
be done to all buildings in the project area.
• Indicate the total acres in the property under review. Of this
acreage, indicate the total acres of earth disturbance for the
proposed activity.
• The return receipt of delivery of this Notice to the Pennsylvania
Historical and Museum Commission.
PHMC requests the following items:
• Photographs of any buildings over 40 years old.
• Site maps of the proposed activity, if available.
SECTION I. SIGNATURE BLOCK
A legally responsible agent of the applicant should complete and sign
the notice. If this form is prepared by someone else, such as a
consultant or contractor, that individual should complete and sign the
notice.

0120-PM-PY0003 Rev. 5/2006
INSTRUCTIONS FOR COMPLETING CULTURAL RESOURCE NOTICE, continued
- 2 -
SECTION B. LOCATION OF PROJECT
County Codes:
01 Adams
24 Elk
47 Montour
02 Allegheny
25 Erie
48 Northampton
03 Armstrong
26 Fayette
49 Northumberland
04 Beaver
27 Forest
50 Perry
05 Bedford
28 Franklin
51 Philadelphia
06 Berks
29 Fulton
52 Pike
07 Blair
30 Greene
53 Potter
08 Bradford
31 Huntingdon
54 Schuylkill
09 Bucks
32 Indiana
55 Snyder
10 Butler
33 Jefferson
56 Somerset
11 Cambria
34 Juniata
57 Sullivan
12 Cameron
35 Lackawanna 58 Susquehanna
13 Carbon
36 Lancaster
59 Tioga
14 Centre
37 Lawrence
60 Union
15 Chester
38 Lebanon
61 Venango
16 Clarion
39 Lehigh
62 Warren
17 Clearfield
40 Luzerne
63 Washington
18 Clinton
41 Lycoming
64 Wayne
19 Columbia
42 McKean
65 Westmoreland
20 Crawford
43 Mercer
66 Wyoming
21 Cumberland 44 Mifflin
67 York
22 Dauphin
45 Monroe
23 Delaware
46
Montgomery
99
Out of State
PA Dept. of Environmental Protection
SE Regional Office
2 East Main Street
Norristown, PA 19401-4915
Phone: (484) 250-5900
Counties:
Bucks, Chester, Delaware, Montgomery and Philadelphia
PA Dept. of Environmental Protection
NE Regional Office
Two Public Square
Wilkes-Barre, PA 18711-0790
Phone: (570) 826-2511
Counties:
Carbon, Lackawanna, Lehigh, Luzerne, Monroe,
Northampton, Pike, Schuylkill, Susquehanna, Wayne and Wyoming
PA Dept. of Environmental Protection
SC Regional Office
909 Elmerton Avenue
Harrisburg, PA 17110-8200
Phone: (717) 705-4700
Counties:
Adams, Bedford, Berks, Blair, Cumberland, Dauphin,
Franklin, Fulton, Huntingdon, Juniata, Lancaster, Lebanon, Mifflin,
Perry and York
PA Dept. of Environmental Protection
NC Regional Office
208 West 3rd Street, Suite 101
Williamsport, PA 17701-6448
Phone: (717) 570-3636
Counties:
Bradford, Cameron, Clearfield, Centre, Clinton, Columbia,
Lycoming, Montour, Northumberland, Potter, Snyder, Sullivan, Tioga
and Union
PA Dept. of Environmental Protection
SW Regional Office
400 Waterfront Drive
Pittsburgh, PA 15222-4745
Phone: (412) 442-4000
Counties:
Allegheny, Armstrong, Beaver, Cambria, Fayette, Greene,
Indiana, Somerset, Washington and Westmoreland
PA Dept. of Environmental Protection
NW Regional Office
230 Chestnut Street
Meadville, PA 16335-3481
Phone: (814) 332-6945
Counties:
Butler, Clarion, Crawford, Elk, Erie, Forest, Jefferson,
Lawrence, McKean, Mercer, Venango and Warren
PA Dept. of Environmental Protection
Central Office
400 Market Street
P.O. Box 8554
Harrisburg, PA 17105-8554
Phone: (717) 787-5027
PA Dept. of Environmental Protection
Oil and Gas Management
Rachel Carson State Office Building
5th Floor
400 Market Street
P.O. Box 8765
Harrisburg, PA 17105-8765
Phone: (717) 772-2199
PA Dept. of Environmental Protection
Oil and Gas Management
Northwest Regional Office
230 Chestnut Street
Meadville, PA 16335-3481
Phone: (814) 332-6860
PA Dept. of Environmental Protection
Oil and Gas Management
Southwest Regional Office
400 Waterfront Drive
Pittsburgh, PA 15222-4745
Phone: (412) 442-4000
DEP REGIONAL AND CENTRAL OFFICES
DEP OIL AND GAS OFFICES

0120-PM-PY0003 Rev. 5/2006
INSTRUCTIONS FOR COMPLETING CULTURAL RESOURCE NOTICE, continued
- 3 -
PA Dept. of Environmental Protection
Greensburg District Office
Armbrust Professional Center
8205 Route 819
Greensburg, PA 15601
Phone: (724) 925-5500
Counties:
Allegheny, Armstrong, Beaver, Fayette, Greene,
Washington and Westmoreland
PA Dept. of Environmental Protection
Cambria District Office
286 Industrial Park Road
Ebensburg, PA 15931-4119
Phone: (814) 472-1900
Counties:
Bedford, Blair, Cambria, Fulton, Huntingdon, Indiana and
Somerset
PA Dept. of Environmental Protection
Pottsville District Office
5 West Laurel Boulevard
Pottsville, PA 17901-2454
Phone: (570) 621-3118
Counties:
Adams, Berks, Bucks, Carbon, Chester, Columbia,
Cumberland, Dauphin, Delaware, Franklin, Juniata, Lackawanna,
Lancaster, Lebanon, Lehigh, Luzerne, Mifflin, Monroe, Montgomery,
Montour, Northampton, Northumberland, Perry, Philadelphia, Pike,
Schuylkill, Snyder, Susquehanna, Union, Wayne, Wyoming, and York
DEP DISTRICT MINING OFFICES
PA Dept. of Environmental Protection
Moshannon District Office
186 Enterprise Drive
Philipsburg, PA 16866-1860
Phone: (814) 342-8200
Counties:
Bradford, Cameron, Centre, Clearfield, Clinton, Lycoming,
Potter, Sullivan and Tioga
PA Dept. of Environmental Protection
California District Office
25 Technology Drive
California Technology Park
Coal Center, PA 15423-1051
Phone: (724) 769-1100
Serving:
All of Western Pennsylvania
PA Dept. of Environmental Protection
Knox District Office
White Memorial Building
P.O. Box 669
Best Avenue
Knox, PA 16232-0669
Phone: (814) 797-1191
Counties:
Butler, Clarion, Crawford, Elk, Erie, Forest, Jefferson,
Lawrence, McKean, Mercer, Venango and Warren

0120-PM-PY0003a
Rev. 5/2006
- 1 -
DEP/PHMC POLICIES AND PROCEDURES
IMPLEMENTATION OF THE HISTORY CODE
LIST OF EXEMPTIONS
May 2006
These DEP Permits are …Unless
Exempt…these qualifying condit
FOR ALL BUREAUS
Permitted activities which may affect Historic
Resources on the National Register of Historic
Places are not exempt regardless of size.
A.
BUREAU OF AIR QUALITY
Air Quality Plan
Air Quality Operating Permit
Exempt unless more than 10 acres of earth
disturbance.
B.
BUREAU OF WASTE MANAGEMENT
Projects which do not involve earth
disturbance
Facilities operating under permit-by-rule
provisions
C.
BUREAU OF RADIATION PROTECTION
Naturally Occurring and Accelerator Produced
Radioactive Materials (NARM) Licenses
D.
BUREAU OF OIL AND GAS MANAGEMENT
Individual Well Permits
(normally only ½ to 1½ acre in size)
DEP contracts for plugging wells
Well registration
Pillar Permits
Underground Injection Control Permit
NGPA Gas Well Classification Determinations
Clean Streams Law Part II Permits for
disposal wells and treatment facilities
Exempt unless more than 10 acres of earth
disturbance.

0120-PM-PY0003a
Rev. 5/2006
- 2 -
DEP/PHMC POLICIES AND PROCEDURES
IMPLEMENTATION OF THE HISTORY CODE
LIST OF EXEMPTIONS
May 2006
These DEP Permits are …Unless
Exempt…these
ng conditions
qualifyiapply.
FOR ALL WATER MANAGEMENT BUREAUS
The following Water Management permits are
exempt unless the project also requires a NPDES
Individual Permit for Storm Water Discharges
Associated with Construction Activities (NPDES
Construction Permit) and the earth disturbance is
greater than 10 acres.
E.
BUREAU OF WATERSHED MANAGEMENT
I.
Division of Waterways, Wetlands and
Stormwater Management
1.
Chapter 105 Emergency Permit
2.
Chapter 105 General Permit
3.
NPDES General Permit for Storm
Water Discharges Associated with
Construction Activities (NPDES
Construction Permit)
4.
NPDES Individual Permit for Storm
Water Discharges Associated with
Construction Activities (NPDES
Construction Permit)
II. Division of Water Use Planning
1.
Water Allocation Permit
III. Division of Conservation Districts and
Nutrient Management
1.
CAFOs
Exempt unless more than 10 acres of earth
disturbance.
F.
BUREAU OF WATER STANDARDS AND
FACILITY REGULATION
I.
Division of Planning and Permits
1.
National Pollutant Discharge
Elimination System (NPDES) Permit
for Sewage Discharge
2.
Water Quality Management (Permit -
Sewage Treatment Plants, Pump
Stations or Sewer Extensions)
3.
General National Pollutant Discharge
Elimination System (NPDES) Permits
4.
National Pollutant Discharge
Elimination System (NPDES) Permit
for Industrial Wastewater
5.
General Water Quality Management
Permits.
6.
Water Quality Management Permit
(Industrial Wastewater)

0120-PM-PY0003a
Rev. 5/2006
- 3 -
These DEP Permits are …Unless
Exempt…these
ng conditions
qualifyiapply.
7.
Planning Approval Under the Sewage
Facilities Act
a.
Component 1 – Exception to the
Requirement to Revise the
Official Plan
b.
Component 2 – Individual and
Community Onlot Disposal of
Sewage
c.
Component 3 – Sewage
Collection and Treatment
Facilities
d.
Component 3s – Small Flow
Treatment Facilities
e.
Exemption from Sewage
Facilities Planning
Exempt unless more than 10 acres of each
disturbance.
Exempt unless more than 10 acres of earth
disturbance.
Exempt unless more than 10 acres of earth
disturbance.
II. Division of Operations Monitoring and
Training
1.
Public Water Supply Permits that do
not involve any earth moving activity
2.
Public Water Supply Permits for wells
3.
Other Public Water Supply Permits
Exempt unless more than 10 acres of earth
disturbance.
G.
BUREAU OF WATERWAYS ENGINEERING
I.
Division of Dam Safety
1.
Limited Power Permit –Major Water
Power Project
H.
BUREAU OF MINING AND RECLAMATION
Permit Renewals/Transfers
Permits for Small Non-Coal Mining (<2,000
tons per year)
Permits for Non-Coal Mining <10,000 tons per
year
Coal/Non-Coal Exploration Notices
Deep Mine Provisions
Bonding authorizations within an approved
Surface Mining Permit
Strip mine reclamation using on-site previously
disturbed material
Portals without permanent linings or facings
Exploratory drilling or well drilling
Abandoned mine refuse pile grading or fire
extinguishment
Drainage control work in previously disturbed
areas
Abandoned coal refuse piles

0120-PM-PY0003a
Rev. 5/2006
- 4 -
These DEP Permits are …Unless
Exempt… these
ng conditions
qualifyi
apply.
I.
BUREAU OF ABANDONED MINE
RECLAMATION (March 31, 1993 memo
between Bureau and BHP of PHMC)
Strip mine reclamation using on-site previously
disturbed material
Backfilling or flushing deep mines
Backfilling or capping vertical mine openings
Portals without permanent linings or facings
Exploratory drilling or well drilling
Abandoned mine refuse pile grading or fire
extinguishment
Abandoned deep mine dangerous gas venting
projects
Drainage control work in previously disturbed
areas
Abandoned coal refuse piles

0120-PM-PY0003a
Rev. 5/2006
- 5 -
PHMC’S TIME FRAMES
No.
PHMC Survey (Phase 1 & 2)
90 days in December, January and
February, 60 days in other months.
PHMC
Determination
in 15 days.
PHMC
Determination
In 15 days.
Applicant
Submits
Notice
Significant
Survey
Completed
End
End
End
Phase 3
Needed?
Yes.
Yes.
PHMC Field Investigation
(Phase 3)
In 120 days in December, January and February.
In 90 days in other months, unless applicant
agrees to time extension.
No.

0120-PM-PY0003 Rev. 5/2006
COMMONWEALTH OF PENNSYLVANIA
DEP USE ONLY
NOTICE
DEPARTMENT OF ENVIRONMENTAL PROTECTION
Date Received
CULTURAL RESOURCE NOTICE
Read the instructions before completing this form.
SECTION A. APPLICANT IDENTIFIER
Applicant Name
Street Address
City
State
Zip
Telephone Number
Project Title
SECTION B. LOCATION OF PROJECT
Municipality
County Name
DEP County Code
SECTION C. PERMITS OR APPROVALS
Name of Specific DEP Permit or Approval Requested:
Anticipated federal permits:
Surface Mining
404 Water Quality Permit
Army Corps of Engineers
Federal Energy Regulatory Commission
401 Water Quality Certification
Other:
SECTION D. GOVERNMENT FUNDING SOURCES
State:
(Name)
Local:
(Name)
Federal:
(Name)
Other:
(Name)
SECTION E. RESPONSIBLE DEP REGIONAL, CENTRAL, DISTRICT MINING or OIL & GAS MGMT OFFICE
DEP Regional Office Responsible for Review of Permit Application
Central Office (Harrisburg)
Southeast Regional Office (Norristown)
Northeast Regional Office (Wilkes-Barre)
Southcentral Regional Office (Harrisburg)
Northcentral Regional Office (Williamsport)
Southwest Regional Office (Pittsburgh)
Northwest Regional Office (Meadville)
District Mining Office:
Oil & Gas Office:
SECTION F. RESPONSIBLE COUNTY CONSERVATION DISTRICT, if applicable.
County Conservation District
Telephone Number, if known
SECTION G. CONSULTANT
Consultant, if applicable
Street Address
City
State
Zip
Telephone Number

0120-PM-PY0003 Rev. 5/2006
- 2 -
SECTION H. PROJECT BOUNDARIES AND DESCRIPTION
REQUIRED
Indicate the total acres in the property under review. Of this acreage, indicate the total acres of earth
disturbance for the proposed activity.
Attach a 7.5' U.S.G.S. Map indicating the defined boundary of the proposed activity.
Attach photographs of any building over 50 years old. Indicate what is to be done to all buildings in the project
area.
Attach a narrative description of the proposed activity.
Attach the return receipt of delivery of this notice to the Pennsylvania Historical and Museum Commission.
REQUESTED
Attach photographs of any building over 40 years old.
Attach site map, if available.
SECTION I. SIGNATURE BLOCK
Applicant’s Signature
Date of Submission of Notice to PHMC

0120-PM-PY0003 Rev. 5/2006
Checklist
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
CULTURAL RESOURCE NOTICE
APPLICANT’S
?
CHECKLIST
Please check the following list to make sure that you have included all the required information. Place a checkmark in the
column provided for all items completed and/or provided.
Failure to provide all of the requested information will delay the processing of the application and may result in the
application being placed on hold
with no action, or will be considered withdrawn and the application file closed.
Requirement
Check
?
If
Included
1.
Attachments, where appropriate
a) Section B - Additional municipality information.
b) Section B - Additional county information.
c) Section H - 7.5' USGS Map (with defined boundaries of proposed activity).
d) Section H - Narrative description of proposed activity.
e) Section H - Photographs of any buildings over 50 years old. Indicate what is to be done to all
buildings in the project area.
f) Section H - Total acres in property under review. Of this acreage, total acres of earth disturbance for
the proposed activity.
g) Return receipt of delivery of Cultural Resource Notice to the Pennsylvania Historical and Museum
Commission.
2.
Mailings
a) Notice mailed to PHMC on
.
b) Received return receipt from PHMC on
.
c) Submitted application to DEP Regional, Central, District Mining or Oil and Gas Mgmt. Office on
with copy of return receipt from PHMC as proof of submittal.
or
d) Submitted application to County Conservation District Office on
with copy of
Return Receipt from PHMC as proof of submittal.
Requests
Check
?
If
Included
3.
Attachments requested, where appropriate
a) Section H - Photographs of any buildings over 40 years old.
b) Section H - Site maps of the proposed activity, if available.

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
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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

3150-PM-BWEW0550
Rev. 6/2016
- 1 -
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WATERWAYS ENGINEERING AND WETLANDS
Request for a Bog Turtle Habitat Evaluation (Phase 1 Survey)
Federal/State Screening Process for Bog Turtles (Glyptemys muhlenbergii) and/or their habitat in
Adams, Berks, Bucks, Carbon (Aquashicola Creek Watershed only), Chester, Cumberland,
Dauphin (Swatara Creek Watershed only), Delaware, Franklin (Antietam Creek Watershed),
Lancaster, Lebanon, Lehigh, Monroe, Montgomery, Northampton, Schuylkill (Swatara Creek
Watershed only), and York Counties.
If you are proposing work in wetlands in the counties listed above and have not completed the
Endangered Species coordination process with the U.S. Fish and Wildlife (USFWS), you may complete this
form and necessary accompanying information and submit to the points of contact listed below to have
the required Phase 1 Survey completed; or have an environmental consultant complete the Phase I survey
field work and documentation and submit to the USFWS for review and approval. To expedite the review
process, applicants may have the Phase I survey completed by a qualified bog turtle surveyor. More
information on the bog turtle and a listing of USFWS qualified surveyors can be found on the USFWS
website:
www.fws.gov/northeast/pafo/
In 1974 the Pennsylvania Fish and Boat Commission, under Section 2305 of the Fish and Boat Code, listed the
bog turtle as an endangered species, and in 1997 the USFWS, under the Endangered Species Act of 1973, listed
the bog turtle as a threatened species. Poaching and loss of habitat are two primary reasons for the decline in
turtle populations throughout the Mid-Atlantic Region.
In order to provide continued protection for the turtle and to minimize conflicts during project development and
permitting, the U.S. Army Corps of Engineers, USFWS, and PA Department of Environmental Protection have
developed a screening process to identify potential bog turtle habitat. Representatives of these agencies will
provide guidance regarding this special screening process for projects that may impact wetlands in the counties
listed above.
INSTRUCTIONS
If your proposed project includes a
wetland impact
in one of the seventeen counties listed above, and you are
requesting a bog turtle habitat screening from the agencies, follow the steps below:
1. Run a Pennsylvania Natural Diversity Inventory (PNDI) data search at:
conservationexplorer.state.pa.us/
. If
PNDI search receipt indicates further consultation with USFWS, follow instructions in “AGENCY COMMENTS
section of the PNDI Receipt. For all other results, go to Step 2.