3930-PM-WM0511 7/2004 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION BUREAU OF WATERSHED MANAGEMENT WATER OBSTRUCTION AND ENCROACHMENT DEP USE ONLY Acknowledged Date GP PASPGP-2 Authorization included: YES NO Transfer Date BWM-GP-11 GENERAL PERMIT REGISTRATION Maintenance, Testing, Repair, Rehabilitation, or Replacement of Water Obstructions and Encroachments SECTION A. APPLICANT INFORMATION Check One: New Permit Transfer of Existing Permit complete Sections A, C & H and transfer form - 3930-PM-WM0016 Existing Permit(s) Number for Project(s) with a Submerged Lands License Agreement (if applicable) N/A Applicant Name PENNSYLVANIA DEPARTMENT OF TRANSPORTATION Contact Person Last Name First Name MI Telephone SWAN KRISTEN (814) 696-6827 Mailing Address City State Zip + 4 1620 NORTH JUNIATA STREET HOLLIDAYSBURG PA 16648 Email Address kswan@state.pa.us SECTION B. CONSULTANT (if applicable) Consultant - Last Name First Name MI Smith Raymond L Consulting Firm The EADS Group Mailing Address City State Zip + 4 1126 Eighth Avenue Altoona PA 16602 Telephone FAX Email (814) 944-5035 (814) 944-4862 rsmith@eadsgroup.com - 1 -
3930-PM-WM0511 7/2004 SECTION C. INSTRUCTIONS If you have any questions concerning whether your project qualifies for GP-11 please contact your regional office (Exhibit B). 1. Prepare a project location map using the appropriate portion of the USGS 7½ Minute Quadrangle Map or other suitable mapping with the project site(s) identified. Number each activity making sure it corresponds with the activity number found in the Project Inventory Chart (Section D1). 2. Project Description: Describe the project in enough detail to allow Department to determine that the proposed work complies with both the terms and environmental and engineering conditions of the General Permit. (A project can be one structure or a series of structures that are related to one another located in one county.) See Attached Project Description (attach additional sheets if necessary) 3. Using the Project Inventory Chart (Section D1), list each water obstruction and/or encroachment that requires maintenance. Please fill out the row for each activity in its entirety. Please make sure the activity number corresponds with the area identified on the site location map. 4. If you are proposing a bridge or culvert replacement or the proposed work will change the waterway opening, please complete and provide the chart in Section D2. If the project consists of similar work (replacement or change in waterway opening) on more than one structure, submit the data requested in Section D2 for each structure included in this registration. 5. For bridges and culverts across a watercourse which are to be used by the general public such as an access to an industrial, commercial, or residential development, etc., plans, specifications and hydrologic and hydraulic reports shall be prepared and submitted by a registered professional engineer and shall be affixed with their seal and certification. 6. For bridge or culvert replacements, activities that reduce the size of the waterway opening, or work on a structure that poses a threat to human life or a substantial potential risk to property, plans, specifications and hydrologic and hydraulic reports shall be prepared and submitted by a registered professional engineer and shall be affixed with their seal and certification. - 2 -
PROJECT DESCRIPTION for SR 4015, Section 001 - Bridge Replacement Over Bells Gap Run Antis Township, Blair County, Pennsylvania Project Description This project is the replacement of a deteriorating two-span steel I-beam bridge carrying S.R. 4015 over Bell s Gap Run in Antis Township, Blair County with a single-span prestressed concrete adjacent box beam bridge. The bridge is located north of the community of Bellwood. (See Location Maps, Appendix A) The bridge will be placed on the existing horizontal alignment. A construction baseline is used to tie the proposed roadway to the existing roadway, leading into the bridge, because the existing roadway centerline has moved from the right-of-way centerline over years of widening and resurfacing. The vertical alignment is raised to maintain the existing 100- year floodwater elevation. The approach roadway work is kept to a minimum. The length of vertical curve required to tie the bridge grade to the existing roadway using a 30mph design speed establishes the limits of work. The length of the reconstructed roadway, including the bridge, is 575 feet. The grade for the roadway is controlled by the bridge elevations. The grade was determined by holding the existing low chord elevation, assuming the use of 8-30 inch deep adjacent concrete box beams, applying the deck depth (including a 2.5 inch bituminous surface course), and the appropriate shoulder and roadway cross slopes. The break point for the roadway and shoulder is at the edge of the 11-foot lane. The roadway grade of 0.6% is used on the bridge and ties to the existing vertical alignment with vertical curves. The vertical alignment ties to the existing vertical alignment in a curve. To ensure a smooth pavement transition within a curve the contractor will mill the existing pavement and resurface the roadway form the P.C. of the curve to the point of pavement reconstruction. Traffic will be detoured during construction. SR 4015 will be closed at the intersections with SR 4020 and 0865. Traffic will travel south on SR 0865 to the intersection with SR 4019 in Bellwood. From there it will travel south on SR 4019 to the intersection with SR 4020. From this intersection traffic will proceed north on SR 4020 to SR 4015. A 30-inch pipe will be constructed across the roadway to carry surface runoff to Bells Gap Run. The pipe will outlet into a ditch that parallels Bells Gap Run. This ditch eventually meets the main stream. -2a-
This pipe is also the outlet of a private pond that is adjacent to the roadway, just south of the bridge. This pond is not a flood control structure and appears to serve no purpose other than as a recreational facility. The property that the pond is on also has a smaller pond west of the above pond. This pond also has no apparent use other than recreational. The Blair Gap Water Supply Company, a predecessor of the Altoona Water Authority, once owned the property in question. According to the FEMA Report there was a dam just upstream of the bridge. The dam has since been removed. Neither pond will be impacted by this project. Wetland Impacts Two palustrine emergent wetlands (PEM) have been identified in the project area. One, located in the area between the existing roadway and the larger of the two ponds adjacent to the project area (west of roadway), will be impacted by the project. The planned fill slope (for roadway widening) will impact an area of 0.0051-acres (223.70 square feet) of wetland 1. Wetland 2 is located to the east of the roadway, opposite of wetland one, and will not be impacted by the project. Deminimus wetlands impacts will be accounted for at the Mowry Advanced Wetland Compensation site as a good faith effort towards the Net Loss policy. Environmental Treatment during construction Stream diversion devices will be constructed at each abutment permitting work to be performed in a dry environment. The existing pier will be demolished and removed with equipment located behind the stream diversion device at the near abutment. The bridge will be constructed behind shoring to limit the extent of excavation (in the direction of the stream) required for the new structure foundations. This project is estimated to be a borrow project. To accommodate the proposed structure, the existing road will be raised slightly. As a result, a fair amount of embankment will be constructed. The toe of the embankments will be protected with silt barrier fence throughout the construction area. The silt fence will be erected parallel to contours and extended a minimum of 8 feet up the slope and an angle of 45 degrees. Protective fencing will be installed to protect adjacent wetlands not directly impacted by the proposed construction. Inlet filter bags will be used to protect all functioning inlets from sediment accumulation. All slopes will be seeded immediately upon their completion to prevent erosion. As soon as vegetation becomes established with 80% cover, erosion control devices will be removed from the project area. -2b-
3930-PM-WM0511 7/2004 Activity Number** Type of Water Obstruction (Bridge, Culvert, Utility Stream Crossing, Utility Wetland Crossing) SECTION D1. PROJECT INVENTORY For Blair Activity Type (Maintenance, testing, repair, rehabilitation, or replacement) Earth Disturbance (acres) Name of USGS Quadrangle Map Municipality Where Project is Located County* Name of Stream 1 Bridge Replacement 0.818 Bellwood, PA Antis Twp Bells Gap Run TSF Chapter 93 Stream Designation Special PFBC Designation (Wild Trout, Stocked Trout, Migratory Fishes) Wild Trout, Stocked Trout 2 30 Culvert Pipe Replacement 0.073 Bellwood, PA Antis Twp Unnamed Tributary to Bells Gap Run TSF 3 4 5 6 7 8 9 10 11 *For multiple structures attach additional sheets that provide the same information requested in the chart. **The number used for a particular water obstruction from Section D1 should match the number in Section D2 for the same water obstruction. - 3 -
3930-PM-WM0511 7/2004 SECTION D2. BRIDGE AND/OR CULVERT REPLACEMENT PROJECTS OR PROJECTS THAT CHANGE THE WATERWAY OPENING* Bridge/Culvert Existing Bridge/Culvert Proposed Activity Number** Waterway Opening (sq. ft.) (span (ft.) x underclearance (ft.)) Span (ft.) Underclearance (ft.) Length (ft.) (upstream to downstream) Material Type (RCP, CMP, etc.) Waterway Opening (sq. ft.) (span (ft.) x underclearance (ft.)) Span (ft.) Underclearance (ft.) Length (ft.) (upstream to downstream) Material Type (RCP, CMP, etc.) 1 416.77 64.02 6.51 22 2-Span Steel Girder 582.76 84.58 6.89 29 Single Span P/S Concrete Adjacent Box Beam 2 0.79 N/A 1.0 38 CMP 4.91 N/A 2.5 166 RCP 3 4 5 6 7 8 9 10 11 *For multiple structures attach additional sheets that provide the same information requested in the chart. **The number used for a particular water obstruction from Section D1 should match the number in Section D2 for the same water obstruction. - 4 -
3930-PM-WM0511 7/2004 SECTION E. COMPLIANCE REVIEW Is the applicant (owner and/or operator) currently in violation of any permits issued by the Department? If yes, please provide: 1. Permit Number: 2. Nature of the violation (if any): 3. Status of violation (i.e., schedule for compliance, etc.): SECTION F. OTHER PERMITS Are any other Chapter 105 permits required for this project? SECTION G. CERTIFICATION I certify that the information provided in this permit registration is true and correct to the best of my knowledge and information. Signature of Permittee (Person Responsible for Installation, Operation and Maintenance of Authorized Activity) Date Type or Print Name AN ACKNOWLEDGED COPY OF THIS GENERAL PERMIT AND THE EROSION AND SEDIMENT CONTROL PLAN REVIEWED BY THE DEP REGIONAL OFFICE MUST BE AVAILABLE AT THE PROJECT SITE DURING CONSTRUCTION. - 5 -
3930-PM-WM0511 7/2004 SECTION H. REGISTRATION CHECKLIST In order to register use of this General Permit, confirm the following: I/we have notified the Municipality and County. I/we hereby notify the Department that BDWM-GP-8, Temporary Road Crossing will also be utilized during the maintenance activity. Please Submit: Completed Permit Registration Form. LOCATION MAP. An 8 ½ by 11 photocopy of a portion of the U.S.G.S. 7 ½ Minute Quadrangle Map or suitable mapping with the project site(s) identified. Wetland Information Data Sheets, Field tes, or Photos of the wetland area. Engineering plan or sketch drawing that provides the necessary information. Project cross-section drawing. Completed copy of a PNDI Search Form (Supplement. 1) with Search Receipt. For bridge or culvert replacements, activities that reduce the size of the waterway opening, or work on a structure that poses a threat to human life or a substantial potential risk to property, plans, specifications and hydrologic and hydraulics report shall be prepared and submitted by a registered professional engineer and shall be affixed with their seal and certification. Erosion and Sediment Control Plan for earth disturbance activities Any existing Submerged Lands License Agreements Please submit where required: Photographs For projects involving a waterway opening, photos upstream and downstream of the existing structure are required. Bog Turtle Habitat Screening Form (where required). This screening is required for General Permits 5, 6, 7, 8, 9, and 11 which may impact wetlands in the following counties: Adams, Berks, Bucks, Chester, Cumberland, Delaware, Franklin, Lancaster, Lebanon, Lehigh, Monroe, Montgomery, rthampton, Schuylkill (Swatara Watershed), and York. - 6 -
3930-PM-WM0511 7/2004 SECTION I1. DRAWINGS/PLANS 1) Engineering drawings prepared and sealed by a Professional Engineer are required for the following types of projects: a) bridge and culvert replacements b) activities that reduce the size of the waterway opening c) bridges or culverts across a watercourse which are to be used by the general public d) work on a structure that poses a threat to human life or a substantial potential risk to property 2) Prepared plans or sketch plans maybe submitted for activities not listed in 1 a) through d). *Please make sure the information below is provided on all engineering plans, drawings, and other prepared plans or sketch plan required for registration. SECTION I2. DRAWINGS/PLANS CHECKLIST YES N/A YES N/A Stream Impacts with Dimensions Total Length 100 Total sq. ft. 6,725 Wetland Acreage Onsite 0.04+ Permanent Wetland Impacts 223.7 sq. ft. Stream Name Bells Gap Run Chapter 93 Stream Designation TSF Location of Property Lines Relative to the Project Existing Utilities Temporary Wetland sq. ft. Proposed Utilities Stream Limits and Flow Direction Floodway Limits (if known) *Shown on Plan Profile Limits of Earth Disturbance Associated with this Activity Use the next sheet for sketch if applicable Existing Buildings, Roadways, Other Structures Proposed Buildings, Roadways, Other Structures Other Waters (i.e. pond, lakes) Please indicate rth Please indicate photo locations - 7 -
3930-PM-WM0511 7/2004 SKETCH PLAN (if applicable) PADOT Applicant Name Please refer to Exhibit E, Engineering Plans and Cross Sections. Scale 1" = ft. - 8 -
3930-PM-WM0511 7/2004 PROJECT CROSS SECTIONS PADOT Applicant Name Provide a cross section of the project if not included on the Engineering Drawings, showing the dimensions of the waterway opening, area of fill materials used, and other pertinent information necessary to accurately depict the scope of your project, and allow the Department to determine that the project complies with the terms and conditions of this General Permit. Please refer to Exhibit E, Engineering Plans and Cross Sections. - 9 -
8000-PM-IT0001 Rev 06/07/2002 CHECKLIST COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION GENERAL INFORMATION FORM -- AUTHORIZATION APPLICATION APPLICANT S CHECKLIST This final checklist is to assist the applicant in assuring that all requests for responses, contacts, additional documentation, etc. have been addressed. Please check the following list to make sure that you have included all the required information. 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 will be considered withdrawn and the application file closed. This applicant s checklist need not be returned to DEP with your completed application. REQUIREMENTS 1. ATTACHMENTS. The completion of the GIF may require the submission of some or all of the following. Where appropriate, include the appropriate attachment(s) with the completed GIF. a) Site Information, Written Directions to Site - Attach additional sheets as necessary. b) Facility Information, Latitude/Longitude Attach additional sheets as necessary. c) Project Information, Project Description Attach additional sheets as necessary. d) Project Information, Time Schedules -- Attach additional sheets as necessary. e) Land Use Information If the project has already received local planning approvals, building permits or special exemptions or conditional approvals to the local zoning ordinance, attach such documentation if possible. If the site is grand-fathered as a pre-existing use or a vested right, document that information as well. If the early opt-out option is being used, attach approval letters from local municipality(ies) and county(ies) where project is being proposed. For more information on this, see the GIF Instructions and the Department s policy on the land use review process for permitting Document ID: 012-0200-001. f) Coordination Information - If land is disturbed, it may be the applicant s responsibility to also notify the PA Historical and Museum Commission, Bureau of Historic Preservation, 400 rth Street, Floor 2, Harrisburg, PA 17120-0093, (717) 787-3362. PHMC notification is required for: 1) purposes of construction activities for Individual NPDES permits disturbing 10 or more acres; and 2) Erosion & Sediment Control permits. General NPDES permits disturbing 10 or more acres are exempt from PHMC notification. For additional information, see Cultural Resource tice instructions to determine whether submission of information to PHMC is required for this permit application. g) Coordination Information, Question 9.0.1 Attach copy Act 537 Approval Letter. te: Approval required prior to 105/NPDES approval. h) Coordination Information, Question 16.0.2 Attach copy - Public Water Supplier s Agreement Letter to Serve the Project. 2. CONTACTS MADE. According to information provided in the Coordination Information section, the appropriate DEP office may need to be contacted; as well as some agencies outside DEP. See the Instructions document for appropriate contact per coordination question. In addition to contacts referenced above, prior to proceeding with any project, DEP encourages applicants to be in touch with municipal and county governments to get information on and secure, if possible, any local permits or approvals that might be required for the project. By doing so, potential conflicts at the local level can be resolved prior to application submission to DEP. 3. BEFORE YOU DIG -- CONTACT. Pennsylvania One Call System at 1-800-242-1776. 4. APPLICATION SUBMITTED. Application has been completed and properly signed according to instructions and type codes; and will be submitted to the appropriate DEP office. Page 1
8000-PM-IT0001 Rev 06/07/2002 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 62214 State - State Agency Organization Name or Registered Fictitious Name Employer ID# (EIN) Dun & Bradstreet ID# PENNSYLVANIA DEPARTMENT OF TRANSPORTATION 25-6003105 Individual Last Name First Name MI Suffix SSN N/A Additional Individual Last Name First Name MI Suffix SSN N/A Mailing Address Line 1 Mailing Address Line 2 PENNSYLVANIA DEPARTMENT OF TRANSPORTATION 1620 NORTH JUNIATA STREET Address Last Line City State ZIP+4 Country HOLLIDAYSBURG PA 16648 USA Client Contact Last Name First Name MI Suffix SWAN KRISTEN Client Contact Title Phone Ext DISTRICT REGULATORY PERMIT COORDINATOR 814-696-6827 Email Address FAX kswan@state.pa.us 814-696-7203 SITE INFORMATION DEP Site ID# Site Name SR 4015 Section 001 EPA ID# Estimated Number of Employees to be Present at Site 0 Description of Site BRIDGE REPLACEMENT & ROADWAY IMPROVEMENT County Name Municipality City Boro Twp State BLAIR ANTIS County Name Municipality City Boro Twp State Site Location Line 1 Site Location Line 2 Site Location Last Line City State ZIP+4 Detailed Written Directions to Site US RT. 220 TO BELLWOOD, SR 0865 NORTH TO SR 4015, LEFT ONTO SR 4015 TO BRIDGE SITE Site Contact Last Name First Name MI Suffix YOCUM THOMAS Site Contact Title Site Contact Firm DISTRICT ENVIRONMENTAL MANAGER PENNSYLVANIA DEPARTMENT OF TRANSPORTATION Mailing Address Line 1 Mailing Address Line 2 ENGINEERING DISTRICT 9-0 1620 NORTH JUNIATA STREET Mailing Address Last Line City State ZIP+4 HOLLIDAYSBURG PA 16648 Phone Ext FAX Email Address 814-696-7224 814-696-7203 tyocum@state.pa.us Page 1 of 7
8000-PM-IT0001 Rev 06/07/2002 NAICS Codes (Two- & Three-Digit Codes List All That Apply) 6-Digit Code (Optional) 221, 234, 484 Client to Site Relationship OWNOP 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: Transportation Latitude/Longitude Latitude Longitude Point of Origin Degrees Minutes Seconds Degrees Minutes Seconds 40 36 35 78 21 50 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 Reference Point Code 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 Geometric Type Code Data Collection Date Source Map Scale Number Inch(es) = Feet --or-- Centimeter(s) = Meters PROJECT INFORMATION Project Name SR 4015 Section 001 Project Description BRIDGE REPLACEMENT & ROADWAY IMPROVEMENT Project Consultant Last Name First Name MI Suffix Smith Raymond L Project Consultant Title Consulting Firm Project Manager The EADS Group Mailing Address Line 1 Mailing Address Line 2 The EADS Group, Inc. 1126 Eighth Avenue Address Last Line City State ZIP+4 Altoona PA 16602 Phone Ext FAX Email Address 814-944-5035 814-944-4862 rsmith@eadsgroup.com Page 2 of 7
8000-PM-IT0001 Rev 06/07/2002 Time Schedules Project Milestone (Optional) 1. Is this application for an authorization type on the list of authorizations affected by the land use policy? te: If, you must complete the following Land Use Information section, unless exempted by Questions 2 or 3 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. For an Air program authorization only. All other authorizations continue with Question 3 below. Will the permit authorize the construction of facilities outside an existing permitted area? te: If, you must complete the following Land Use Information section unless exempted by Question 3 below. If, skip Question 3 below as well as the following Land Use Information section. 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
8000-PM-IT0001 Rev 06/07/2002 COORDINATION INFORMATION te: The PA Historical and Museum Commission must be notified of proposed projects in accordance with DEP Technical Guidance Document 012-0700-001 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 3.0. 1.0 Is this a coal mining project? If, respond to 1.1-1.6. 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 2.1-2.6. 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
8000-PM-IT0001 Rev 06/07/2002 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 3.1-3.3. 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) 4.0.1 Total Disturbed Acreage 0.85 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) 8.0.1 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) 9.0.1 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/4X62) 10.0.1 Gallons Per Year (residential septage) 10.0.2 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) 11.0.1 Dam Name 12.0 Will the project interfere with the flow from, or otherwise impact, a dam? If, identify the dam. (DEP Use/3140) 12.0.1 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) 13.0.1 Enter all types & amounts of emissions; separate each set with semicolons. Page 5 of 7
8000-PM-IT0001 Rev 06/07/2002 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) 14.0.1 Number of Persons Served 14.0.2 Number of Employee/Guests 14.0.3 Number of Connections 14.0.4 Sub-Fac: Distribution System 14.0.5 Sub-Fac: Water Treatment Plant 14.0.6 Sub-Fac: Source 14.0.7 Sub-Fac: Pump Station 14.0.8 Sub-Fac: Entry Point 14.0.9 Sub-Fac: Transmission Main 14.0.10 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) 15.0.1 Provider s Name 15.0.2 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) 16.0.1 Supplier s Name 16.0.2 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) 17.0.1 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) 18.0.1 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) 20.0.1 Enter all substances & capacity of each; separate each set with semicolons. 21.0 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) 21.0.1 Enter all substances & capacity of each; separate each set with semicolons. 22.0 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) 22.0.1 Enter all substances & capacity of each; separate each set with semicolons. Page 6 of 7
8000-PM-IT0001 Rev 06/07/2002 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) 23.0.1 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 Signature Title Date Page 7 of 7