Project Information Section:

1. Fill out items requested with current Information.
2. Use area provided or attach a sheet containing a complete description of the project including, but not limited to a discussion of construction methods.

Permit Being Requested:

1. Check whether permit is reporting or non-reporting (review nationwide permit terms in January 15, 2002 Federal Register Part VII to determine nationwide reporting status.
2. For non-reporting nationwide permits, provide expiration date (expiration date will be two (2) years from the date the form is completed).

Corps Authority Information:

1. Section 10: tell whether or not the area within Corps jurisdiction is a Section 10 water [Section 10 waters include all declared navigable water (see list provided by Corps of Engineers) or areas reached by the ebb and flow of the tide].
2. Section 404: Tell whether area is a Section 404 waters [Section 404 waters include areas below the ordinary high water mark in an area containing a bed and bank (waterway) or areas classified as wetlands according to the 1987 Manual].

Permit Compliance:

Compliance with Nationwide General Conditions

1. Navigation: State whether the project will have an adverse impact on navigation (consider all forms of navigation including shipping, recreational boating, etc.).
2. Proper Maintenance: Specify how the structure will be maintained in the future to ensure public safety.
3. Erosion and Siltation Controls: Explain how erosion and siltation controls will be used and maintained during construction.
4. Aquatic Life Movements: Specify if the project will disturb the movement of aquatic life indigenous to the waterbody including migration
5. Equipment: Explain measures taken to minimize soil disturbance in wetlands.
6. Regional and Case-by-Case Conditions: Explain how the project complies with regional and/or case-by-case conditions imposed by the Corps District Engineer.
7. Wild and Scenic Rivers: Specify if project will affect a component of the National Wild and Scenic River System or a river officially designated by Congress as a "study river" for possible inclusion in the system. If a wild and scenic or study river will be affected, the Applicant must obtain written approval from the appropriate Federal land management agency in the area (e.g., National Parks Service, U.S. Forest Service, etc.).
8. Tribal Rights:Explain if the project will impair reserved tribal rights, including but not limited to reserved water rights and treaty fishing and hunting rights.
9. Water Quality Certification: Provide dates of water quality certification from the Regional Water Quality Control Board (note all nationwide permits, including non-reporting nationwide permits require certification or waiver of certification by the RWQCB).
10. Coastal Zone Management: State coastal management consistency must be obtained for the nationwide permit to be considered valid.
11. Endangered Species: Provide list of all Federally-listed endangered species that could potentially occur within the project area.  For the species identified as potentially occurring in the project area, describe why or why not it may occur in the project.  For those species that could be affected by the project, contact the lead Federal agency for the project for a written determination of no affect, may affect or not likely to adversely affect.  The lead federal agency shall initiate consultation (formal and/or informal) for all determinations with the exception of no affect.  The written determination by the federal lead agency and the written result of consultation shall be provided to the Corps.  If the project will jeopardize the continued existence of a federally listed threatened or endangered species or species proposed for such designation then an individual permit must be secured.  If the project might affect a federally listed species or species proposed for such designation then a non-reporting nationwide permit can not be obtained.
12. Historic Properties: Non-reporting nationwide permits cannot be obtained for projects where historic properties listed or eligible for listing in the National Register of Historic Places. If such a property shall be affected, then the Applicant shall notify the Corps.
13. Notification: Review terms of all numbered nationwide permits that you will use for your project to determine if Corps notification is necessary. The Corps requires 30 days from the receipt of a complete application (45 days for Nationwide Permit 26) to process an application. Notification must include name, address and telephone numbers of the prospective permittee; location of the proposed project; brief description of the proposed project, project purpose, direct and indirect adverse environmental effects, and any other Corps permits used or intended to be used to authorize any part of the proposed project. Nationwide permits 14, 18, 21, 26, 29 34 and 38 must include a delineation of affected special aquatic sites, including wetlands. NWP 33 must include a restoration plan of reasonable measures to avoid and minimize adverse effects to aquatic resources.
14. Compliance Certification: Complete compliance certification that accompanies a written authorization from the Corps and returned it to the Corps upon completion of the project. The Certification shall include a statement that the work was don in accordance with the Corps authorization and a statement that any required mitigation was completed in accordance with permit conditions.
15. Multiple Use of Nationwide Permits: In any case where nationwide permit 12 through 40 is combined with any other nationwide permit 12 through 40 as part of a single and complete project, a non-reporting nationwide permit may not be used. In such cases, the applicant must notify the Corps and obtain written authorization form the Corps.
16. Water Supply Intakes: Explain if the project would result in the discharge of material in the proximity of a public water supply intake.
17. Shellfish: Explain if discharge of dredged or fill occurs in areas of concentrated shellfish production.
18. Suitable Material: Explain if discharge of dredged or fill material consists of unsuitable material (e.g., trash, debris, car bodies, asphalt, etc.). Describe if material is free from toxic pollutants in toxic amounts.
19. Mitigation: Explain how discharge into Corps jurisdiction has been minimized or avoided to the maximum extent practicable. If impacts are not minimized to the satisfaction of the Corps, a mitigation plan to compensate for impacts shall be attached.
20. Spawning Areas: Describe if the project will affect spawning areas.
21. Obstruction of High Flows: Explain if the project will create an impoundment of water and if that impoundment would cause an adverse effect on the aquatic system.
22. Waterfowl Breeding Areas: Explain if discharges will occur in breeding areas for migratory waterfowl.
23. Removal of Temporary Fills: Explain how all temporary fills will be removed and the area returned to its pre-existing elevation.

Nationwide Permit Number and Title:

Provide the number(s) and title(s) of all nationwide permits to be used for the project.

Special Conditions:

Give any special conditions that shall be enforced at the site. For example include any measures designed to protect listed species, location of all environmentally sensitive area (ESA) boundaries, etc.

Project Impact Information:

Wetlands (permanent): Provide the acreage and cubic yardage of permanent fill in wetland areas.

Wetlands (temporary): Provide the acreage and cubic yardage of temporary fill in wetland areas.

Waters of the US (permanent): Provide the acreage and cubic yardage of permanent fill in waters of the U.S.

Waters of the US (temporary): Provide the acreage and cubic yardage of temporary fill in waters of the U.S.

Linear Feet of Streambank Affected (Nationwide 13, 14, and/or 26):For these nationwide permits, include the amount (linear footage) of streambed that will be affected by the project. To calculate, consider the length of streambed affected on each bank and add together for a combined total.

Project Mitigation Information:

1. Best Management Practices: List BMPs that will be used at the site to reduce erosion and siltation.
2. Proposed Restoration: List measures that will be implemented to return the site to pre-project conditions.
3. Proposed mitigation (if any): Provide a mitigation plan that will be implemented either on- or off-site to compensate for impacts to aquatic resource functions and values.

Attachments:

1. Site Location Map: Provide site location map along with this completed form.
2. Delineation of Jurisdictional Boundaries: Delineation of jurisdictional boundaries shall be provided on an aerial photo or contour map. The delineation shall be prepared by a qualified biologist. The delineation shall encompass all areas of work within a closed polygon labeled project boundary. All wetlands and waters of the US shall be depicted on the map and in a legend using Xerox-reproducible symbols. Data points shall be marked on the map.
3. Completed Routine Data Forms: Completed data forms used to prepare the delineation shall accompany the delineation map.
4. Reduced Project Plans showing all proposed impacts to aquatic resources: Attach all project plans (11x17) or smaller showing the location of project impacts to Corps jurisdiction, including permanent and temporary fill.
5. Mitigation Information: Attach all mitigation information (e.g., mitigation site plans, monitoring plans, etc.) to the completed form.
6. Copy of applicable nationwide permit(s) and general conditions: For non-reporting nationwide permits, include a copy of the general conditions along with any term of numbered nationwide permit along with this completed form. These items are to be available to the contractor when bidding the project and shall also be placed in the Resident Engineers file at the job site.

Copies

1. Non-Reporting Nationwide Permits:
   
   1. A completed copy of this form and all attachments listed above shall be available as documentation of the permit in the Environmental Planning project files.
   2. A copy of the completed application and attachments shall be provided to the District Office Engineer for inclusion in the PS&E package.
   3. The completed application and package shall also be provided to the District project manager.
   4. A completed copy of the form and attachments shall be placed in the Resident Engineer's file in the event of a field inspection by the Corps.
   5. A copy of the completed form and attachments may be sent to the Corps for review and concurrence. If sent, specify that the content is a non-reporting nationwide permit and no written response is required.
2. Reporting Nationwide Permits:
   A copy of the completed form and all attachments shall be forwarded to the Corps.