Section A Permit Application. This section contains the Joint Permit Application and General Information Form.

Transcription

1 Section A Permit Application This section contains the Joint Permit Application and General Information Form.

2 3930-PM-WM0036A Rev. 11/2001 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION and DEPARTMENT OF ARMY CORPS OF ENGINEERS (Baltimore, Philadelphia, and Pittsburgh Districts) Coordination # JOINT APPLICATION FOR PENNSYLVANIA WATER OBSTRUCTION AND ENCROACHMENT PERMIT AND U.S. ARMY CORPS OF ENGINEERS SECTION 404 PERMIT Before completing this form, please read the step-by-step instructions and Section F Application Completeness Checklist provided with this Joint Permit package. AGENCY USE ONLY Application ID# (Assigned by DEP) Program Application. RECEIVED DATE REQUIRED APP. FEE CHECK NO. AMOUNT $ SECTION A. APPLICATION TYPE: STANDARD SMALL PROJECTS SECTION B. APPLICANT IDENTIFIER Applicant Name Pennsylvania Department of Transportation, Engineering District 2-0 SECTION C. PROJECT LOCATION DATA Name of stream and/or body of water. Duck Run Corps District where project will occur. Baltimore Philadelphia Pittsburgh Name of the U.S.G.S. 7 1/2 Minute Quadrangle Map where project is located: Mill Hall, PA Indicate location of project on this map by measuring (in inches) from the lower right corner: rth (up) 11.75" inches; West (to the left) 12.75" inches; Latitude 41d3'52" ; Longitude 77d28'3" Project type, purpose and need: The purpose of this project is to improve the roadway geometry and replace the structure facility on S.R.2004 for public use. SECTION D. PROJECT STATUS HAS ANY PORTION OF PROPOSED PROJECT BEEN COMPLETED? yes no date completed If yes, attach description of those portions of the project that have been completed and identify dates of completion. SECTION E. OTHER APPROVALS LIST APPROVALS, CERTIFICATIONS, DENIALS OR NOTICES OF VIOLATION RECEIVED FROM FEDERAL, INTERSTATE, STATE OR LOCAL AGENCIES FOR STRUCTURES, CONSTRUCTION, DISCHARGES OR OTHER ACTIVITIES DESCRIBED IN THIS APPLICATION

3 3930-PM-WM0036A Rev. 11/2001 SECTION F. APPLICATION COMPLETENESS CHECKLIST (Applicant must place an entry - Y =, N =, N/A = t Applicable - in each left side column space. See Section for additional details. If you are applying under the Small Projects Application format, place an entry in only those comments prefixed by an asterisk (*). REQUIREMENT Applicant Entry DEP Use Only a. GIF and permit application properly signed, sealed and witnessed *Y b. Application Fee enclosed (see Section G.) *N/A c. Copies and proof of receipt - Act 14 notification - Acts 67/68/127 *Y d. Cultural Resource tice - Copy and Proof of Receipt *Y e. Completed and approved Supplement. 1 Form (PNDI search) *Y f. Plans (site plan including cross sections and profiles for Subsections 151, 191, 231, 261) g. Location map Y h. Project description narrative *Y i. Color photographs with map showing location taken *Y j. Environmental Assessment form *Y k. Erosion and Sediment Control Plan and approval letter Y l. Hydrologic and hydraulic analysis Y m. Stormwater Management Analysis w/consistency letter Y n. Floodplain Management Analysis w/consistency letter Y o. Risk Assessment Y p. Professional engineer s seal and certification Y q. Alternative analysis Y r. Mitigation plan Y SECTION G. DETERMINATION OF APPLICATION FEES (DEP FEES ONLY) Types of Water Obstructions and Encroachments Number of Units Fee Per Unit Subtotal Amount Stream enclosures $ $ Channel changes $ $ Commercial dredging $ $ Peat extraction $ $ Fills, levees, floodwalls $ $ Bridges and other water obstructions and encroachments $ $ Small projects ($100 fee regardless of number of units) $ $ Qualifies for General Permit (fee waived) $0.00 N/A Make Check Payable to: Commonwealth of Pennsylvania TOTAL FEE $ List each type and number of water obstructions and encroachments that are included in this application and indicate subtotal and total fee amounts. *Y FAILURE TO PROVIDE ALL OF THE REQUESTED INFORMATION WILL DELAY THE PROCESSING OF THE APPLICATION AND MAY RESULT IN THE APPLICATION BEING PLACED ON HOLD WITH NO ACTION, OR IT MAY BE CONSIDERED WITHDRAWN AND THE FILE CLOSED

4 3930-PM-WM0036A Rev. 11/2001 SECTION H. ADJOINING PROPERTY OWNERS Please list the name and address of all property owners whose land adjoins the project property. NAME ADDRESS Stephen Grieb R.R. #4, Box 879, Mill Hall, PA John E. & Mellanie A. Boone Forrest F. & Janice N. Gundlach 602 Mackeyville Rd., Mill Hall, PA Mackeyville Rd., Mill Hall, PA SECTION I. CERTIFICATION AND SIGNATURE If Privately Owned, all owners (such as husband and wife) must sign. One or more members authorized to sign on behalf of an entire partnership must sign. For a Corporation, the president, vice president or other responsible official is required to sign. For Political Subdivision, signatures of the chief officer or other responsible official empowered to sign is required with the seal affixed and attested by the clerk. For Commonwealth departments, boards, commissions, receivers, trustees and authorities, a department head, bureau director, executive director, chairman, commissioner or other responsible official is required to sign. Signatures other than above must be accompanied by a power of attorney or other notarized legal documentation indicating authorization to sign on behalf of the applicant. Application is hereby made for a permit to authorize the activities described herein. I certify I am familiar with the information contained in this application, and to the best of my knowledge and belief, such information is true, complete and accurate. I further certify I possess the authority to undertake the proposed activities. I certify that the project proposed in this application complies with and will be conducted in a manner that is consistent with the approved Coastal Zone Management program of the Commonwealth of Pennsylvania. (Only portions of Erie, Bucks, Philadelphia, Delaware Counties are in the Coastal Zone). I grant permission to the agencies responsible for authorization of this work, or their duly authorized representative, to enter the project site for inspection purposes during working hours. I will abide by the conditions of the permit or license if issued and will not begin work without the appropriate authorization. By: Kevin R. Kline, P.E. (PRINT NAME) (SIGNATURE) (DATE) SEAL (TITLE) WITNESS: - 3 -

5 FORM COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION GENERAL INFORMATION FORM AUTHORIZATION APPLICATION Before completing this General Information Form (GIF), read the step-by-step instructions provided in this application package. This version of the General Information Form (GIF) must be completed and returned with any programspecific application being submitted to the Department. Related ID#s (If Known) DEP USE ONLY Client ID# APS ID# Date Received & General tes Site ID# Auth ID# Facility ID# CLIENT INFORMATION DEP Client ID# Client Type / Code State / State Agency Organization Name or Registered Fictitious Name Employer ID# (EIN) Dun & Bradstreet ID# Pennsylvania Department of Transportation - District 2-0 Individual Last Name First Name MI Suffix SSN Kline Kevin R P.E. Additional Individual Last Name First Name MI Suffix SSN Mailing Address Line 1 Mailing Address Line Daisy Street Extension, P.O. Box 342 Address Last Line City State ZIP+4 Country Clearfield PA Client Contact Last Name First Name MI Suffix Kline Kevin R P.E. Client Contact Title Phone Ext District Executive (814) Address FAX (814) SITE INFORMATION DEP Site ID# Site Name State Route 2004, Section A03 over Duck Run EPA ID# Estimated Number of Employees to be Present at Site 5 Description of Site Bridge replacement over Duck Run County Name Municipality City Boro Twp State Clinton Lamar Township PA County Name Municipality City Boro Twp State Site Location Line 1 Site Location Line 2 S.R. 2004, Section A03; Segment 0140, Offset 0610 Site Location Last Line City State ZIP+4 Mill Hall PA Detailed Written Directions to Site Take US-220 south out of Williamsport. Stay south on US-220 for about 32 miles. Turn Right onto SR 2008 and follow to SR Turn Right onto SR Follow SR 2004 to project site over Duck Run Site Contact Last Name First Name MI Suffix LaParne Benjamin R. P.E. Site Contact Title Site Contact Firm Assistant District Executive Pennsylvania Department of Transportation Mailing Address Line 1 Mailing Address Line Daisy Street Extension, P.O. Box 342 Mailing Address Last Line City State ZIP+4 Clearfield PA Page 1 of 7

6 Phone Ext FAX Address (814) (814) NAICS Codes (Two- & Three-Digit Codes List All That Apply) 6-Digit Code (Optional) Client to Site Relationship Owner / Operator FACILITY INFORMATION Modification of Existing Facility 1. Will this project modify an existing facility, system, or activity? 2. Will this project involve an addition to an existing facility, system, or activity? If, check all relevant facility types and provide DEP facility identification numbers below. Facility Type DEP Fac ID# Facility Type DEP Fac ID# Air Emission Plant Beneficial Use (water) Blasting Operation Captive Hazardous Waste Operation Coal Ash Beneficial Use Operation Coal Mining Operation Coal Pillar Location Commercial Hazardous Waste Operation Dam Location Deep Mine Safety Operation -Anthracite Deep Mine Safety Operation -Bituminous Deep Mine Safety Operation -Ind Minerals Encroachment Location (water, wetland) Erosion & Sediment Control Facility Explosive Storage Location Industrial Minerals Mining Operation Laboratory Location Land Recycling Cleanup Location MineDrainageTrmt/LandRecyProjLocation Municipal Waste Operation Oil & Gas Encroachment Location Oil & Gas Location Oil & Gas Water Poll Control Facility Public Water Supply System Radiation Facility Residual Waste Operation Storage Tank Location Water Pollution Control Facility Water Resource Other: Latitude/Longitude Latitude Longitude Point of Origin Degrees Minutes Seconds Degrees Minutes Seconds Mill Hall, PA Horizontal Accuracy Measure Feet or-- Meters Horizontal Reference Datum Code rth American Datum of 1927 rth American Datum of 1983 World Geodetic System of 1984 Horizontal Collection Method Code ITPMP Reference Point Code CNTR Altitude Feet or-- Meters Altitude Datum Name The National Geodetic Vertical Datum of 1929 The rth American Vertical Datum of 1988 (NAVD88) Altitude (Vertical) Location Datum Collection Method Code SRVY, PHGRM, TOPO Geometric Type Code POINT Data Collection Date Source Map Scale Number 1 Inch(es) = 2000 Feet --or-- Centimeter(s) = Meters PROJECT INFORMATION Project Name Bridge Replacement over Duck Run Project Description Replacement of existing two-span bridge with a new single-span bridge, including associated roadway approach improvements, at the same location. Project Consultant Last Name First Name MI Suffix Schweiss Perry M. P.E. Project Consultant Title Consulting Firm Vice-President of Operations SPK Engineering, Inc. Mailing Address Line 1 Mailing Address Line Kaider Road Page 2 of 7

7 Address Last Line City State ZIP+4 Uniontown PA Phone Ext FAX Address Time Schedules Project Milestone (Optional) Let Date 1. Is this application for an authorization type on the list of authorizations affected by the land use policy? te: If, continue with Question 2 below. If, skip Questions 2 & 3 below as well as the following Land Use Information section. For referenced list, see Appendix A attached to the GIF Instructions. 2. If you are applying for an Air program authorization, does the permit authorize the construction of facilities outside an existing permitted area? te: If to Question 1 above and to Question 2, skip Question 3 below as well as the following Land Use Information section. If to both Questions 1 & 2, continue with Question 3 below. 3. Have you attached or submitted municipal and county Early Opt Out approval letters for the project? te: If to Question 3, skip the following Land Use Information section. This should only be checked if applicant is choosing the early opt-out option. Required approval letters described in the GIF Checklist and Instructions should be attached. If to Question 3, continue with the following Land Use Information section. LAND USE INFORMATION te: Applicants are encouraged to submit copies of local land use approvals or other evidence of compliance with local comprehensive plans and zoning ordinances. 1. Is there a municipal comprehensive plan(s)? 2. Is there a county comprehensive plan(s)? 3. Is there a multi-municipal or multi-county comprehensive plan? 4. Is the proposed project consistent with these plans? If no plan(s) exists, answer. 5. Is there a municipal zoning ordinance(s)? 6. Is there a joint municipal zoning ordinance(s)? 7. Will the proposed project require a zoning approval (e.g., special exception, conditional approval, re-zoning, variance)? If zoning approval has already been received, attach documentation. 8. Are any zoning ordinances that are applicable to this project currently the subject of any type of legal proceeding? 9. Will the project be located on a site that has been or is being remediated under DEP s Land Recycling Program? 10. Will the project result in reclamation of abandoned mine lands through remining or as part of DEP s Reclaim PA Program? 11. Will the project be located in an agricultural security area or an area protected under an agricultural conservation easement? 12. Will the project be located in a Keystone Opportunity Zone or Enterprise Development Area? 13. Will the project be located in a Designated Growth Area as defined by the Municipalities Planning Code? Page 3 of 7

8 COORDINATION INFORMATION te: The PA Historical and Museum Commission must be notified of proposed projects in accordance with DEP Technical Guidance Document and the accompanying Cultural Resource tice Form. If the activity will be a mining project (i.e., mining of coal or industrial minerals, coal refuse disposal and/or the operation of a coal or industrial minerals preparation/processing facility), respond to questions 1.0 through 2.5 below. If the activity will not be a mining project, skip questions 1.0 through 2.5 and begin with question Is this a coal mining project? If, respond to If, skip to Question 2.0. (DEP Use/48y1) 1.1 Will this coal mining project involve coal preparation/ processing activities in which the total amount of coal prepared/processed will be equal to or greater than 200 tons/day? (DEP Use/4x70) 1.2 Will this coal mining project involve coal preparation/ processing activities in which the total amount of coal prepared/processed will be greater than 50,000 tons/year? (DEP Use/4x70) 1.3 Will this coal mining project involve coal preparation/ processing activities in which thermal coal dryers or pneumatic coal cleaners will be used? (DEP Use/4x70) 1.4 For this coal mining project, will sewage treatment facilities be constructed and treated waste water discharged to surface waters? (DEP Use/4x62) 1.5 Will this coal mining project involve the construction of a permanent impoundment meeting one or more of the following criteria: (1) a contributory drainage area exceeding 100 acres; (2) a depth of water measured by the upstream toe of the dam at maximum storage elevation exceeding 15 feet; (3) an impounding capacity at maximum storage elevation exceeding 50 acre-feet? (DEP Use/3140) 1.6 Will this coal mining project involve underground coal mining to be conducted within 500 feet of an oil or gas well? (DEP Use/4z41) 2.0 Is this a non-coal (industrial minerals) mining project? If, respond to If, skip to Question 3.0. (DEP Use/48y1) 2.1 Will this non-coal (industrial minerals) mining project involve the crushing and screening of non-coal minerals other than sand and gravel? (DEP Use/4x70) 2.2 Will this non-coal (industrial minerals) mining project involve the crushing and/or screening of sand and gravel with the exception of wet sand and gravel operations (screening only) and dry sand and gravel operations with a capacity of less than 150 tons/hour of unconsolidated materials? (DEP Use/4x70) 2.3 Will this non-coal (industrial minerals) mining project involve the construction, operation and/or modification of a portable non-metallic (i.e., non-coal) minerals processing plant under the authority of the General Permit for Portable n-metallic Mineral Processing Plants (i.e., BAQ-PGPA/GP-3)? (DEP Use/4x70) 2.4 For this non-coal (industrial minerals) mining project, will sewage treatment facilities be constructed and treated waste water discharged to surface waters? (DEP Use/4x62) 2.5 Will this non-coal (industrial minerals) mining project involve the construction of a permanent impoundment meeting one or more of the following criteria: (1) a contributory drainage area exceeding 100 acres; (2) a depth of water measured by the upstream toe of the dam at maximum storage elevation exceeding 15 feet; (3) an impounding capacity at maximum storage elevation exceeding 50 acre-feet? (DEP Use/3140) Page 4 of 7

9 3.0 Will your project, activity, or authorization have anything to do with a well related to oil or gas production, site development for such activity, or the waste from such a well? If, respond to If, skip to Question 4.0. (DEP Use/4z41) 3.1 Does the oil- or gas-related project involve any of the following: placement of fill, excavation within or placement of a structure, located in, along, across or projecting into a watercourse, floodway or body of water (including wetlands)? (DEP Use/4z41) 3.2 Will the oil- or gas-related project involve discharge of industrial wastewater or stormwater to a dry swale, surface water, ground water or an existing sanitary sewer system or storm water system? If, discuss in Project Description. (DEP Use/4z41) 3.3 Will the oil- or gas-related project involve the construction and operation of industrial waste treatment facilities? (DEP Use/4z41) 4.0 Will the project involve a construction activity that results in earth disturbance? If, specify the total disturbed acreage. (DEP Use/4x66) Total Disturbed Acreage 0.5 acres 5.0 Does the project involve any of the following: placement of fill, excavation within or placement of a structure, located in, along, across or projecting into a watercourse, floodway or body of water (including wetlands)? (DEP Use/4x66) 6.0 Will the project involve discharge of industrial wastewater or stormwater to a dry swale, surface water, ground water or an existing sanitary sewer system or separate storm water system? If, discuss in Project Description. (DEP Use/4x62) 7.0 Will the project involve the construction and operation of industrial waste treatment facilities? (DEP Use/4x62) 8.0 Will the project involve construction of sewage treatment facilities, sanitary sewers, or sewage pumping stations? If, indicate estimated proposed flow (gal/day). Also, discuss the sanitary sewer pipe sizes and the number of pumping stations/treatment facilities/name of downstream sewage facilities in the Project Description, where applicable. (DEP Use/4x62) Estimated Proposed Flow (gal/day) 9.0 Was sewage planning submitted and approved? If, attach the Act 537 approval letter unless the submitted application is actually requesting Act 537 approval (Approval required prior to 105/NPDES approval). (DEP Use/4x61) Is Act 537 Approval Letter attached? 10.0 Is this project for the beneficial use of biosolids for land application within Pennsylvania? If indicate how much (i.e. gallons or dry tons per year). (DEP Use/4X64) Gallons Per Year (residential septage) Dry Tons Per Year (biosolids) 11.0 Does the project involve construction, modification or removal of a dam? If, identify the dam. (DEP Use/3140) Dam Name 12.0 Will the project interfere with the flow from, or otherwise impact, a dam? If, identify the dam. (DEP Use/3140) Dam Name 13.0 Will the project involve operations (excluding during the construction period) that produce air emissions (i.e., NOX, VOC, etc.)? If, identify each type of emission followed by the amount of that emission. (DEP Use/4x70) Enter all types & amounts of emissions; separate each set with semicolons. Page 5 of 7

10 14.0 Is an on-site drinking water supply (well), other than individual house wells, proposed for your project? If, indicate total number of people served and/or the total number of connections served, if applicable. Also, check all proposed sub-facilities. (DEP Use/4x81) Number of Persons Served Number of Employee/Guests Number of Connections Sub-Fac: Distribution System Sub-Fac: Water Treatment Plant Sub-Fac: Source Sub-Fac: Pump Station Sub-Fac: Entry Point Sub-Fac: Transmission Main Sub-Fac: Storage Facility 15.0 Will your project involve purchasing water in bulk, excluding during the construction period? If, name the provider. Also, indicate the daily number of employees or guests served. (DEP Use/4x81) Provider s Name Number of Employees/Guests 16.0 Is your project to be served by public water supply? If, indicate name of supplier and attach letter from supplier stating that it will serve the project. (DEP Use/4x81) Supplier s Name Letter of Approval from Supplier is Attached 17.0 Will this project involve a new or increased drinking water withdrawal from a stream or other water body? If, provide name of stream. (DEP Use/4x81) Stream Name 18.0 Will the construction or operation of this project involve treatment, storage, reuse, or disposal of waste? If, indicate what type (i.e., hazardous, municipal (including infectious & chemotherapeutic), residual) and the amount to be treated, stored, re-used or disposed. (DEP/Use4x32) Type & Amount 19.0 Will your project involve the removal of coal, minerals, etc. as part of any earth disturbance activities? (DEP Use/48y1) 20.0 Does your project involve installation of a field constructed underground storage tank? If, list each Substance & its Capacity. te: Applicant may need a Storage Tank Site Specific Installation Permit. (DEP Use/2570) Enter all substances & capacity of each; separate each set with semicolons Does your project involve installation of an aboveground storage tank greater than 21,000 gallons capacity at an existing facility? If, list each Substance & its Capacity. te: Applicant may need a Storage Tank Site Specific Installation Permit. (DEP Use/2570) Enter all substances & capacity of each; separate each set with semicolons Does your project involve installation of a tank greater than 1,100 gallons which will contain a highly hazardous substance as defined in DEP s Regulated Substances List, 2570-BK-DEP2724? If, list each Substance & its Capacity. te: Applicant may need a Storage Tank Site Specific Installation Permit. (DEP Use/2570) Enter all substances & capacity of each; separate each set with semicolons. Page 6 of 7

11 23.0 Does your project involve installation of a storage tank at a new facility with a total AST capacity greater than 21,000 gallons? If, list each Substance & its Capacity. te: Applicant may need a Storage Tank Site Specific Installation Permit. (DEP Use/2570) Enter all substances & capacity of each; separate each set with semicolons. CERTIFICATION I certify that I have the authority to submit this application on behalf of the applicant named herein and that the information provided in this application is true and correct to the best of my knowledge and information. Type or Print Name Kevin R. Kline, P.E. Signature Title Date Page 7 of 7