Fillable USACE NYSDEC Joint Permit Application Joint Application For Permit

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USACE NYSDEC Joint Permit Application Joint Application For Permit

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U.S.A. forms for Town of Greece

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JOINT APPLICATION FORM
For Permits for activities activities affecting streams, waterways, waterbodies, wetlands, coastal areas, sources of water,
and endangered and threatened species.
You must separately apply for and obtain Permits from each involved agency before starting work. Please read
all instructions.
1. Applications To:
>NYS Department of Environmental Conservation
Check here to confirm you sent this form to NYSDEC.
Check all permits that apply:
Dams and Impound-
ment Structures
401 Water Quality
Certification
Freshwater Wetlands
Tidal Wetlands
Wild, Scenic and
Recreational Rivers
Coastal Erosion
Management
Water Withdrawal
Long Island Well
Incidental Take of
Endangered /
Threatened Species
Stream Disturbance
Excavation and Fill in
Navigable Waters
Docks, Moorings or
Platforms
>US Army Corps of Engineers
Check here to confirm you sent this form to USACE.
Check all permits that apply:
Section 10 Rivers and Harbors Act
Is the project Federally funded?
Yes
No
If yes, name of Federal Agency:
General Permit Type(s), if known:
Preconstruction Notification:
Yes
No
>NYS Office of General Services
Check here to confirm you sent this form to NYSOGS.
Check all permits that apply:
State Owned Lands Under Water
Utility Easement (pipelines, conduits, cables, etc.)
Docks, Moorings or Platforms
>NYS Department of State
Check here to confirm you sent this form to NYSDOS.
Check if this applies:
Coastal Consistency Concurrence
2. Name of Applicant
Taxpayer ID (if applicant is NOT an individual)
Mailing Address
Post Office / City
State
Zip
Telephone
Email
Applicant Must be (check all that apply):
Owner
Operator
Lessee
3. Name of Property Owner (if different than Applicant)
Mailing Address
Post Office / City
State
Zip
Telephone
Email
For Agency Use Only
Agency Application Number:
JOINT APPLICATION FORM 08/16 Page 1 of 4
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JOINT APPLICATION FORM – Continued. Submit this completed page as part of your Application.
4. Name of Contact / Agent
Mailing Address
Post Office / City
State
Zip
Telephone
Email
5. Project / Facility Name
Property Tax Map Section / Block / Lot Number:
Project Street Address, if applicable
Post Office / City
State
Zip
NY
Provide directions and distances to roads, intersections, bridges and bodies of water
Town
Village
City
County
Stream/Waterbody Name
Project Location Coordinates: Enter Latitude and Longitude in degrees, minutes, seconds:
Latitude:
°
'
"
Longitude:
°
'
"
6. Project Description: Provide the following information about your project. Continue each response and provide
any additional information on other pages. Attach plans on separate pages.
a. Purpose of the proposed project:
b. Description of current site conditions:
c. Proposed site changes:
d. Type of structures and fill materials to be installed, and quantity of materials to be used (e.g., square feet of
coverage, cubic yards of fill material, structures below ordinary/mean high water, etc.):
e. Area of excavation or dredging, volume of material to be removed, location of dredged material placement:
f. Is tree cutting or clearing proposed?
Yes If Yes, explain below.
No
Timing of the proposed cutting or clearing (month/year):
Number of trees to be cut:
Acreage of trees to be cleared:
JOINT APPLICATION FORM 08/16 Page 2 of 4
RESET
JOINT APPLICATION FORM – Continued. Submit this completed page as part of your Application.
g. Work methods and type of equipment to be used:
h. Describe the planned sequence of activities:
i. Pollution control methods and other actions proposed to mitigate environmental impacts:
j. Erosion and silt control methods that will be used to prevent water quality impacts:
k. Alternatives considered to avoid regulated areas. If no feasible alternatives exist, explain how the project will
minimize impacts:
l. Proposed use: Private Public Commercial
m. Proposed Start Date:
Estimated Completion Date:
n. Has work begun on project?
Yes If Yes, explain below.
No
o. Will project occupy Federal, State, or Municipal Land?
Yes If Yes, explain below.
No
p.
List any previous DEC, USACE, OGS or DOS Permit / Application numbers for activities at this location:
q.
Will this project require additional Federal, State, or Local authorizations, including zoning changes?
Yes If Yes, list below.
No
JOINT APPLICATION FORM 08/16 Page 3 of 4
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JOINT APPLICATION FORM – Continued. Submit this completed page as part of your Application.
7. Signatures.
Applicant and Owner (If different) must sign the application.
Append additional pages of this Signature section if there are multiple Applicants, Owners or Contact/Agents.
I hereby affirm that information provided on this form and all attachments submitted herewith is true to the best of
my knowledge and belief.
Permission to Inspect - I hereby consent to Agency inspection of the project site and adjacent property areas.
Agency staff may enter the property without notice between 7:00 am and 7:00 pm, Monday - Friday. Inspection
may occur without the owner, applicant or agent present. If the property is posted with "keep out" signs or fenced
with an unlocked gate, Agency staff may still enter the property. Agency staff may take measurements, analyze
site physical characteristics, take soil and vegetation samples, sketch and photograph the site. I understand that
failure to give this consent may result in denial of the permit(s) sought by this application.
False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the NYS
Penal Law. Further, the applicant accepts full responsibility for all damage, direct or indirect, of whatever n
ature,
and by whomever suffered, arising out of the project described herein and agrees to indemnify and save harmless
the State from suits, actions, damages and costs of every name and description resulting from said project. In
addition, Federal Law, 18 U.S.C., Section 1001 provides for a fine of not more than $10,000 or imprisonment for
not more than 5 years, or both where an applicant knowingly and willingly falsifies, conceals, or covers up a
material fact; or knowingly makes or uses a false, fictitious or fraudulent statement.
Signature of Applicant
Date
Applicant Must be (check all that apply):
Owner
Operator Lessee
Printed Name
Title
Signature of Owner (if different than Applicant)
Date
Printed Name
Title
Signature of Contact / Agent
Date
Printed Name
Title
For Agency Use Only DETERMINATION OF NO PERMIT REQUIRED
Agency Application Number
(Agency Name) has determined that No Permit is
required from this Agency for the project described in this application.
Agency Representative:
Printed
Name
Title
Signature
Date
JOINT APPLICATION FORM 08/16 Page 4 of 4
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USACE NYSDEC Joint Permit Application Joint Application For Permit

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Completed 1 November 2019

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