0120-PM-PY0003 Rev. 5/2006
     
     
     
    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 k nown
                   
    SECTION G. CONSULTANT
    Consultant, if applicable      
    Street Address      
    City       State       Zip      
    Telephone Number        
    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

    Back to top



    - 1 -