Fillable Form 3594: BRIDGE PERMIT (BRG) APPLICATION Engineering Department (Teton County Wyoming Government)

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Form 3594: BRIDGE PERMIT (BRG) APPLICATION Engineering Department (Teton County Wyoming Government)

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BRG Permit Application
1
Effective 07/01/2020
BRIDGE PERMIT (BRG) APPLICATION
Engineering Department
320 S. King St.
P.O. Box
3594
Jackson, WY
83001
Phone : (307) 733-3317
www.tetoncountywy.gov
Physical Address:
Lot, Subdivision:
PIDN:
Name:
(must agree with Deed)
Phone:
Mailing Address:
City, State:
Email:
ZIP:
Additional Property Owners*:
*Attach additional forms if there are multiple landowners. This application will not be approved without the signature of all landowners (or their authorized agents).
Name:
Phone:
Mailing Address:
City, State:
Email:
ZIP:
License #:
Phone:
Brief Description:
For Office Use Only
GEC
BDR SWF
FPR
SITE LOCATION: (List all properties effected, if not enough room please attach list.)
Pedestrian bridges do not require a bridge permit unless the project is located within a mapped floodplain.
Please submit BRG applications to the Teton County Engineering Department at 320 S. King St.
Please type or fill out this application, completely.
OWNER: A copy of the Warranty Deed(s) or Contract of Sale must accompany this application.
APPLICANT/AGENT: If the applicant is other than owner, a notarized Teton County Planning & Development Letter of Authorization must accompany this
application. Only the owner or his/her authorized agent may sign the application, correction list or
per
mit.
BRIEF PROJECT DESCRIPTION:
DESIGN ENGINEER: Must be a licensed Professional Engineer.
BRG
BRG Permit Application
2
Effective 07/01/2020
Overall Structure Length (FT):
Maximum Span Length (FT):
Clear Width of Structure (FT):
(Minimum Width 14 FT)
Design Load (Tons):
(Minimum vehicular design load AASHTO HL-93)
Material Composition (concrete, timber, etc.):
Abutments:
Piers:
Superstructure:
Bridge Rail Type:
*Bridge rail is required for bridges open to the public; other bridges subject to the discretion of the Engineer of Record.
Utilities (what utilities, if any, are attached to the bridge or buried in the embankment?):
Estimated Cost of Construction:
*A plaque displaying the bridge weight limits shall be placed at the bridge entrance.
Is the structure located in a *Special Flood Hazard Area?
Yes
No
If so, provide:
Flood Zone Designation:
Flood Insurance Rate Map (FIRM) Panel No:
Map Date:
Base Flood Elevation:
Elevation of the lowest level of the structure:
(i.e. abutments, stringers, etc.)
Lowest elevation of electrical:
Lowest elevation of other service facilities:
*Development in a Special Flood Hazard Area requires both a Design and As-Built Elevation Certificate and may require a Bridge Under Construction Elevation Certificate.
The Elevation Certificates must be executed by a Wyoming licensed Land Surveyor or Professional Engineer.
Are there wetlands located on or adjacent to the site of the proposed structure or access roadway?
Yes
No
Is the property located in an Urban-Wild Land Interface?
Yes*
No
*If yes, a Wildland Assessment is required prior to submitting the permit application. Contact the Fire Marshall at 307-733-4732 to arrange for a meeting.
STRUCTURE INFORMATION:
:
FLOODPLAIN INFORMATION: (See County Floodplain Management Resolution and Flood Insurance Rate Maps (FIRMS),
http://www.tetonwyo.org/538/FEMA-Flood-Insurance-Rate-Maps. Also see the County GIS Map Server Website
https://maps.greenwoodmap.com/tetonwy/mapserver/ Click on the Map Layer Icon to select FEMA Flood Hazard Zones.)
:
WETLANDS: (Identify wetlands and their setbacks on a site plan.)
:
WILDLAND-URBAN INTERFACE: (A Wildland-Urban Interface Area is defined as a geographical area where structures and other
human development meets or intermingles with Wildland or vegetative fuels. See the County GIS Map Server Website:
https://maps.greenwoodmap.com/tetonwy/mapserver/ Click on the Map Layer icon to select the Wildland-Urban Interface Area
Layer.
NOTICE TO DEVELOPERS AND BUILDERS:
The U.S. Army Corps of Engineers regulates the placement of dredged and fill material into wetlands and other waters of the
United States as authorized primarily by Section 404 of the Clean Water Act (33 U.S.C. 1344). The term “waters of the United
States” has been broadly defined as all waters that were, are, or could be used in interstate commerce and includes lakes, rivers,
streams (including ephemeral steams), mud flats, wetlands, sloughs, playa lakes, and ponds. Wetlands are defined as areas that
are inundated or saturated by surface or ground water at a frequency and duration sufficient to support, and under normal
circumstances do support, a prevalence of vegetation typically adapted for life in saturated soil conditions.
Although Teton County regulates wetlands, Teton County does not administer any aspect of the Section 404 program. It is the
landowner’s responsibility to contact the Corps prior to placing any fill in waters of the U.S. The Section 404 program in Wyoming
is administered by the Corps Wyoming Regulator Office located at 2232 Dell Range Boulevard, Suite 210, Cheyenne, Wyoming
82009. Information on Section 404 requirements can be obtained by contacting the Wyoming Regulatory Office at (307) 772-2300
or by visiting its web site at https://www.nwo.usace.army.mil/Locations/District-Offices/Wyoming/.
BRG Permit Application
3
Effective 07/01/2020
Signature of Applicant Date
Print Name Title
For Office Use
Only
Planning Sufficiency declared by: Date:
Planning Review conducted by : Date:
A fee due at the time of submittal – Bridge Permit Fee Schedule
Letter of Authorization if the applicant is other than the property owner.
A copy of the Warranty Deed.
One plan set of legible complete design drawings scaled on 11” x 17” paper.
One PDF set of design drawings and BRG application with all other attachments emailed to permits@tetoncountywy.gov (no larger than 25MB).
Questions about BRG Permit Applications, design plans and any supporting documents should be directed to the Engineering
Department (307-733-3317).
I certify that I have read and examined this application and know the same to be true and correct. All provisions of the laws and
ordinances governing this work will be complied with whether specified herein or not. The granting of this permit does not give
authority to violate or cancel the provisions of any state or local law regulating grading or the performance thereof.
SUBMITTAL REQUIREMENTS:
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Form 3594: BRIDGE PERMIT (BRG) APPLICATION Engineering Department (Teton County Wyoming Government)

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Completed 14 February 2021

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