Fillable OFFICE OF LAND AND STREAMS STREAM ACTIVITY APPLICATION (West Virginia Division of Natural Resources)

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OFFICE OF LAND AND STREAMS STREAM ACTIVITY APPLICATION (West Virginia Division of Natural Resources)

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OFFICE OF LAND AND STREAMS
STREAM ACTIVITY APPLICATION
1
OLS Form 1 (01/20)
1. N
ame of Applicant AND/OR Company
____________________________________________________________________________
Date of Application _____________________________________________________________
2. Complete Mailing Address of Applicant
____________________________________________________________________________
Bil
ling Address (if different)
________
____________________________________________________________________
Telephone Number: ______________________________ Fax: _________________________
E-Mail
Address ________________________________________________________________
3. Authorized Agent Information (i.e. contractor employed by landowner)
Company ___________________________________________________________________
Addr
ess _____________________________________________________________________
Te
lephone Number ____________________________ Fax __________________________
E-Mail Address ______________________________________________________________
PLEAS
E CHECK (√) HERE IF YOU WANT APPROVAL SENT TO AGENT: ______
4. Please √ the proposed use:
Private ________________ Public: _______________ Commercial: ____________
(Personal Use) (Govt Agency) (Business)
5. Name of Waterway (if unnamed or unknown tributary, provide stream it flows into)
______________________________________________________________________________
De
cimal Coordinates of Site Location (if applicable)
Longit
ude ____________________________ Latitude _____________________________
_________
__________ __________________ ___________________
County District (taxable) Closest City or Town
6. Date activity is proposed to commence: _____________________________________
Dat
e activity is expected to be complete: _____________________________________
OFFICE OF LAND AND STREAMS
STREAM ACTIVITY APPLICATION
2
OLS Form 1 (01/20)
7. Is any portion of the activity for which authorization is sought now complete: Yes ____ No _____
(if the answer is yes please give reasons in Section 8 includi
ng month and year the activity was
completed)
8. Describe proposed activity, its purpose and intended use after completion. Type of equipment to be
used in the stream, amount of material to be dredged (if any), plan for disposing of dredged materials,
length of stream/bank to be worked or type and size of structure to be placed in stream. One copy of a
map (topographical or detailed, hand drawn,) showing exact location of work site (enabling Officials
to locate site) must accompany this application, and all other information that may be important to this
application.
(if additional space is required, continue on a separate sheet)
OFFICE OF LAND AND STREAMS
STREAM ACTIVITY APPLICATION
3
OLS Form 1 (01/20)
9. PLEASE CHECK (√) THE PROPOSED WORK TO BE DONE (for more than one crossing please
use Application Table located on DNR OLS website)
____
_ Pipeline (see Section 10)
____
_ Water Withdrawals (see Section 11)
____
_ Bank/Stream Work
Length ____________________________
____ Stabilization ____ Restoration ____ Dredging/ Clean Out
____ Grading ____ Enhancement ____ Channel Change
____
_ Cables
Type of Transmission Line ____________Purpose __________________________
_
____ Culverts (√ one of the following)
____ Temporary ____ Permanent
L
ength _________________ Diameter/Width ________________
____
_ Bridges (√ one of the following)
____ Temporary ____ Permanent
L
ength _________________ Width ________________
____
_ Low Water Fords Type of ford_____________________________________________
__
___ Loading/Docking/Mooring
F
acility Name ________________ Type of Dock ________________
Lengt
h of Dock _________________ Mile Points ________________
____
_ Valley Fill (completely impedes stream)
Facility Name ____________________________ Length of fill ________________
____
_ Rock Fill (stream still flows)
Facility Name ________________________ Length of fill _____________________
____
_ Maintenance Dredging/ Sand and Gravel
Facility Name ______________________ Mile Points ________________________
10. If activity is a pipeline construction (gas, water, sewer) please provide:
Materi
al Pipeline is made of __________________
Siz
e of Pipeline ___________________ Maximum pressure on pipeline ________________
Prov
ide the appropriate Line Number and if a Gathering or Well Line provide the A.P.I Well Number:
Transmission ______ Distribution ______ Gathering ______
A.P
.I Well Number _____________________________
Well Line _________________ Well Name: _______________________
(√ all that apply)
OFFICE OF LAND AND STREAMS
STREAM ACTIVITY APPLICATION
4
OLS Form 1 (01/20)
1
4. I certify that I am familiar with the information in this application, and that to the best of my knowledge
and belief such information is true, complete and accurate.
_______________
______________________
Signature of Applicant or Agent
Office of Land and Streams
324 Fourth Avenue, Room 20
South Charleston, WV 25303
Phone Number: 304-558-3225
Fax Number: 304-558-6048
Website: http://www.wvdnr.gov/REM/default.shtm
11. If activity is a Water Withdrawal please provide:
Estimate of water to be withdrawn per month _______________________________________
Pump Rate __________________________________________________________________
Specific Purpose for Water Withdrawal ____________________________________________
If using water for Oil and Gas Fracking purposes, do you have a DEP Water Withdrawal Plan?
______Yes _______No (If answer is no, see DEP Contact information in section 13)
If there are multiple withdrawal sites please use Application Table located on DNR OLS website.
12. Has any agency denied approval for the activity described herein? Yes _____ No _____
(If yes, give reasons in Section 8 and attach a copy of the denial )
13. Below is a list of entities that may require permits, Please list all approvals or certifications required
by the other Government agencies for the above-described activity:
Issuing Agency: Corps of Engineers-(304) 399-5353 Type of approval: ______________________
Date
of approval: ______________________
(412) 395-7155
Identification No: __________________________
Issuing Agency: County Commission
Type of approval: ______________________
Floo
d Plain Coordinator
Identification No: ___________________________ Date of approval: ______________________
Issuing Agency: City Government Type of approval: _______________________
(if
in city limits the county isn’t needed) Date of approval: _______________________
Identifi
cation No: ____________________________ Date of approval: _______________________
Issuing Agenc
y: DEP – (304) 926-0440 Date of approval: _______________________
Identification No: ____________________________
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OFFICE OF LAND AND STREAMS STREAM ACTIVITY APPLICATION (West Virginia Division of Natural Resources)

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Completed 1 November 2020

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