Application Alteration Form – Fill Out and Use This PDF

JOINT FEDERAL/STATE APPLICATION FOR THE ALTERATION OF ANY FLOODPLAIN,

WATERWAY, TIDAL OR NONTIDAL WETLAND IN MARYLAND

FOR AGENCY USE ONLY
Application Number			Date Determined Complete
Date Received by State			Date(s) Returned
Date Received by Corps
Type of State permit needed			Date of Field Review
Type of Corps permit needed			Agency Performed Field Review

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

•Please submit 1 original and 4 copies of this form, required maps and plans to the Wetlands and Waterways Program as noted on the last page of this form.

•Any application which is not completed in full or is accompanied by poor quality drawings may be considered incomplete and result in a time delay to the applicant.

Please check one of the following:

RESUBMITTAL: APPLICATIONAMENDMENT: MODIFICATIONTOANEXISTINGPERMIT:

JURISDICTIONALDETERMINATIONONLY APPLYINGFORAUTHORIZATION

PREVIOUSLYASSIGNEDNUMBER(RESUBMITTALSANDAMENDMENTS)

DATE

1.APPLICANT INFORMATION: APPLICANT NAME:

A.	Name:				B. Daytime Telephone:
C.	Company:			D. Email Address:

E.Address:

F.

City:

State:

Zip:

AGENT/ENGINEER INFORMATION:

A.

Name:

B.

Daytime Telephone:

C.

Company:

D. Email Address:

E.Address:

F.

City:

State:

Zip:

ENVIRONMENTAL CONSULTANT:

A.

Name:

B.

Daytime Telephone:

C.

Company:

D. Email Address:

E.Address:

F.

City:

State:

Zip:

CONTRACTOR (If known):

A.

Name:

B.

Daytime Telephone:

C.

Company:

D. Email Address:

E.Address:

F.

City:

State:

Zip:

PRINCIPAL CONTACT:

A.

Name:

B.

Daytime Telephone:

C.

Company:

D. Email Address:

E.Address:

F.

City:

State:

Zip:

PCA 13910

OBJ 4142

2.PROJECT DESCRIPTION

a.GIVE WRITTEN DESCRIPTION OF PROJECT:

Has any portion of the project been completed?				Yes			No		If yes, explain
Is this a residential subdivision or commercial development?						Yes			No
If yes, total number of acres on property			acres

b.ACTIVITY: Check all activities that are proposed in the wetland, waterway, floodplain, and nontidal wetland buffer as appropriate.

A.		filling	D.		flooding or impounding	F.			grading
B.		dredging			water	G.			removing or destroying
C.		excavating	E.		draining				vegetation
						H.			building structures

Area for item(s) checked:		Wetland				(sq. ft.) Buffer (Nontidal Wetland Only)				(sq. ft.)
		Expanded Buffer (Nontidal Wetland Only)						(sq. ft.)
Area of stream impact				(sq. ft.)
Length of stream affected					(linear feet)

c.TYPE OF PROJECTS: Project Dimensions

For each activity, give overall length and width (in feet), in columns 1 and 2. For multiple activities, give total area of disturbance in square feet in column 3. For activities in tidal waters, give maximum distance channelward (in feet) in column 4. For dam or small ponds, give average depth (in feet) for the completed project in column 5. Give the volume of fill or dredged material in column 6.

			Maximum/Average		Volume of fill/dredge
Lengt	Width	Area	Channelward	Pond	material (cubic yards)
h
(Ft.)	(Ft.)	Sq. Ft.	Encroachment	Depth	below MHW or OHW
1	2	3	4	5	6

A.Bulkhead

B.Revetment

C.Vegetative Stabilization

D.Gabions

E.Groins

F.Jetties

G.Boat Ramp

H.Pier

I.Breakwater

J.Repair & Maintenance

K.Road Crossing

L.Utility Line

M.Outfall Construction

N.Small Pond

O.Dam

P.Lot Fill

Q.Building Structures

R.Culvert

S.Bridge

T.Stream Channelization

U.Parking Area

V.Dredging

1.

New

2.

Maintenance

3.

Hydraulic

4.

Mechanical

W.Other (explain)

F.Explanation

DescribereasonswhyimpactswerenotavoidedorreducedinQ. AlsocheckItemsG-Pthatapplytoyourproject.
G.			Cost	K.		Parcel size		N.		Safety/public welfare issue
H.			Extensive wetlands on site	L.		Other regulatory		O.		Inadequate zoning
I.			Engineering/design			requirement		P.		Other
			constraints	M.		Failure to accomplish
J.			Other natural features			project purpose

Q.Description

5.LETTER OF EXEMPTION: If you are applying for a letter of exemption for activities in nontidal wetlands and/or their buffers, explain why the project qualifies:

A.		No significant plant or	B.		Repair existing structure/fill
	wildlife value and wetland impact		C.		Mitigation Project
1.		Less than 5,000	D.		Utility Line

		square
		feet	1.			Overhead
2.		In an isolated nontidal	2.			Underground

wetland less than 1 acre in size

E.Other (explain)

F.Check here if you are not applying for a letter of exemption.

IF YOU ARE APPLYING FOR A LETTER OF EXEMPTION, PROCEED TO BLOCK 11

6.ALTERNATIVE SITE ANALYSIS: Explain why other sites that were considered for this project were rejected in M. Also check any items in D-L if they apply to your project. (If you are applying for a letter of exemption, do not complete this block):

A.		1 site	B.		2 - 4 sites	C.				5 or more sites
Alternative sites were rejected/not considered for the following reason(s):
D.		Cost	H.		Greater wetlands	L.				Other
					impact
E.		Lack of availability	I.		Water dependency
F.		Failure to meet project	J.		Inadequate zoning
		purpose	K.		Engineering/design
G.		Located outside			constraints
		general/market area

M.Explanation:

7.PUBLIC NEED: Describe the public need or benefits that the project will provide in F. Also check Items in A-E that apply to your project. (If you are applying for a letter of exemption, do not complete this block):

A.		Economic	C.		Health/welfare	E.		Other
B.		Safety	D.		Does not provide public
					benefits

F.Description

8.OTHER APPROVALS NEEDED/GRANTED:

A. Agency		B. Date			C. Decision			D. Decision		E. Other
			Sought	1. Granted 2. Denied					Date		Status

9.MITIGATION PLAN: Please provide the following information:

a.Description of a monetary compensation proposal, if applicable (for state requirements only). Attach another sheet if necessary.

b.Give a brief description of the proposed mitigation project.

c.Describe why you selected your proposed mitigation site, including what other areas were considered and why they were rejected.

d.Describe how the mitigation site will be protected in the future.

10. HAVE ADJACENT PROPERTY OWNERS BEEN NOTIFIED?:					A.			Yes	B.		No
Provide names and mailing addresses below (Use separate sheet, if necessary):
a.			b.				c.

11.HISTORIC PROPERTIES: Is your project located in the vicinity of historic properties? (For example: structures over 50 years old, archeological sites, shell mounds, Indian or Colonial artifacts). Provide any supplemental information in Section 13.

A. Yes B. No C. Unknown

12.ADDITIONAL INFORMATION: Use this space for detailed responses to any of the previous items. Attach another sheet if necessary:

SUPPLEMENTARY INFORMATION TO BE INCLUDED ON PLANS, DRAWINGS, OR VICINITY MAPS

In addition to the information indicated on the previous pages, you should include the following on the 8 1/2 x 11 site plans and any blueprints you have submitted:

1.Delineation of any wetland buffers or expanded buffers, clearly marked and differentiated.

2.Location of mitigation area, if proposed on the same site as the project.

Note: If you are proposing a complex project you may wish to submit engineering blueprints of your project with the application form to expedite review.

Mitigation Location Map: If you are proposing that nontidal wetland mitigation be done at a different location than the proposed project, you should submit a map showing the location of the mitigation site in relation to the proposed nontidal wetland losses.

WETLAND DELINEATION

Wetlands should be identified according to methods described in the publication Federal Manual Identifying and Delineating Jurisdictional Wetlands. Copies of the manual may be obtained by calling the U. S. Government Printing Office at 202-783-3238 and requesting document #024-010-00-683-8 at a cost of $7.50. Wetlands must be shown on all plans submitted with the application. All wetlands on site must be delineated and shown on the overall site plan. 8½ x 11 inch plans with topography showing relation of the wetlands and project impacts must be submitted. Copies of the wetland reports and data sheets used in making the determination be included with your application submittal.

	Regulatory Agencies
Federal Permits	State Authorizations
U.S. Army Corps of Engineers	MD Dept. of the Environment
Baltimore District	Water Management Administration
Attention: CENAB-OP-R	Tidal Wetlands Division
P. O. Box 1715	1800 Washington Blvd, Ste 430
Baltimore, MD 21203-1715	Baltimore, MD 21230
Telephone: (410) 962-3670	Telephone: (410) 537-3837
Coastal Zone Consistency	MD Dept. of the Environment
Statement	Water Management Administration
	Nontidal Wetlands and Waterways
MD Dept. of the Environment	Division
Water Management Administration	1800 Washington Blvd, Ste 430
Wetlands and Waterways Program	Baltimore, MD 21230
1800 Washington Blvd, Ste 430	Telephone: (410) 537-3768
Baltimore, MD 21230
Telephone: (410) 537-3745