Application For Authorization To Discharge Dredged Or Fill material To isolated Wetlands And Or Waters Of The State {51821}

APPLICATION FOR AUTHORIZATION TO DISCHARGE DREDGED OR FILL MATERIAL TO ISOLATED WETLANDS AND/OR WATERS OF THE STATE State Form 51821 (R2 / 11-15) Indiana Department of Environmental Management INSTRUCTIONS: 1. Read the instruction sheet before filling out this form. 2. You must complete all applicable sections of this form 1. Applicant Information Name of Applicant Mailing address (Street/ PO Box/ Rural Route, City, State, ZIP Code) Name of Agent 2. Agent Information Mailing address (Street/ PO Box/ Rural Route, City, State, ZIP Code) Daytime Telephone Number Fax Number E-mail address (optional) Contact person (required) Daytime Telephone Number Fax Number E-mail address (optional) Contact person 3. Project / Tract Location County U.S.G.S. Quadrangle map name (Topographic map) Nearest city or town Project street address (if applicable) Quarter Section Township Project name or title (if applicable) Range Type of aquatic resource(s) to be impacted (Attach Worksheet One.) Other location descriptions or driving directions 4. Project Purpose and Description (Use additional sheet(s) if required.) Has any construction been started? Yes No If yes, how much work is completed? Purpose of project and overview of activities Anticipated start date (month, day, year) American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 9 5. Avoidance, Minimization, and Mitigation Information: Applicants must answer all of the following questions (Use additional sheet(s) if necessary - provide a detailed response to all applicable questions.) A. For projects with Class II isolated wetlands ­ 1. Is there a reasonable alternative to the proposed activity? 2. Is the proposed activity reasonably necessary or appropriate? B. For projects with Class III wetlands, adjacent wetlands, and/or streams, rivers, lakes or other water bodies ­ 1. Is there a practicable alternative to the proposed activity? 2. Have practicable and appropriate steps to minimize impacts to water resources been taken? Describe all compensatory mitigation required for unavoidable impacts. 6. Drawing / Plan Requirements (Applicants must provide the following.) a. Top/aerial/overhead views of the project site showing existing conditions and proposed construction. b. Cross sectional view of areas of fill or alterations to streams and other waters. c. North arrow, scale, property boundaries. d. Include wetland delineation boundary (if applicable). Label all wetlands (jurisdictional, isolated and exempt) as I-1, I-2, I-3, etc. and the mitigation areas as M-1, M-2, etc. e. Location of all surface waters, including wetlands, erosion control measures, existing and proposed structures, fill and excavation locations, disposal area for excavated material, including quantities, and wetland mitigation site (if applicable). f. Approximate water depths and bottom configurations (if applicable). 7. Supplemental Application Materials (Applicants must provide the following.) a. b. c. d. e. f. g. A wetland delineation of all wetlands on the project site (for projects with wetland impacts). At least three photographs of the project site. Indicate the photo locations on the project plans. If isolated wetlands are present, a letter from the Corps of Engineers verifying this statement. Wetland mitigation plan and monitoring report. Classification of all isolated wetlands on the tract (if isolated wetlands are present onsite). Copies of all applicable local permits and/or resolutions pertaining to the project or tract. Tract history (see instructions). 8. Additional information that MAY be required (IDEM will notify you if needed.) a. b. c. d. e. Erosion control and/or storm water management plans. Sediment analysis. Species surveys for fish, mussels, plants and threatened or endangered species. Stream habitat assessment. Any other information IDEM deems necessary to review the proposed project. Page 2 of 9 American LegalNet, Inc. www.FormsWorkFlow.com 9. Permitting Requirements a. Does this project require the issuance of a Department of the Army Section 404 Permit from the US Army Corps of Engineers? If no, you do not need to answer Part b. b. Have you applied for an Army Corps of Engineers Section 404 permit? Yes No Yes No If yes, please supply the Corps of Engineers ID Number, the Corps of Engineers District, the project manager, and a copy of any correspondence with the Corps. If no, contact the Army Corps of Engineers regarding the possible need for a permit application. c. Have you applied for, received, or been denied a permit from the Department of Natural Resources for this project? Please give the permit name, permit number, and date of application, issuance or denial. Yes No d. Have you applied for, received, or been denied any other federal, state, or local permits, variances, licenses, or certifications for this project? Yes No Please give the permit name, agency from which it was obtained, permit number, and date of issuance or denial. 10. Adjoining Property Owners and Addresses List the names and addresses of landowners adjacent to the property on which your project is located and the names and addresses of other persons (or entities) potentially affected by your project. Use additional sheet(s) if required. Name Address (number and street) City Name Address (number and street) City Name Address (number and street) City Name Address (number and street) City Name Address (number and street) City Name Address (number and street) City State ZIP Code State ZIP Code State ZIP Code State ZIP Code State ZIP Code State ZIP Code Name Address (number and street) City Name Address (number and street) City Name Address (number and street) City Name Address (number and street) City Name Address (number and street) City Name Address (number and street) City State ZIP Code State ZIP Code State ZIP Code State ZIP Code State ZIP Code State ZIP Code American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 9 11. Signature - Statement of Affirmation I certify that I am familiar with the information contained in this application and, to the best of my knowledge and belief, such information is true and accurate. I certify that I have the authority to undertake and will undertake the activities as described in this application. I am aware that there are penalties for submitting false information. I understand that any changes in project design subsequent to IDEM's granting of authorization to discharge to a water of the state are not authorized and I may be subject to ci