SECTION 401 WQC REGIONAL GENERAL PERMIT NOTIFICATION State Form 51937 (R3 / 8-08) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT INSTRUCTIONS: 1. Familiarize yourself with the terms and conditions and read the instructions before filling out this form. 2. All applicable sections of this two page form must be completed. Date Received: FOR IDEM USE ONLY IDEM ID: APPLICANT INFORMATION Agent: Applicant: Contact person: Contact person: Address (number and street, city, state and ZIP code): Address (number and street, city, state and ZIP code): Telephone number: Telephone number: E-mail address: E-mail address: PROJECT LOCATION Nearest Town: County: Quad Name: Section: Township: Range: Project Address and Driving Directions: EXISTING CONDITIONS ON THE PROJECT SITE LAKE: YES NO LAKE NAME: STREAM: YES NO STREAM NAME: WETLAND(S): YES NO Acreage on the site by wetland type(s): ________ emergent ________ scrub-shrub Date of Wetland Delineation? ______/______/______ ________ forested Date of U.S. Army Corps of Engineers jurisdiction correspondence? ______/______/______ Activity Description: PROJECT IMPACTS Purpose of project: FOR LAKE IMPACT; (acceptable fill defined in instructions) Linear feet of shoreline impact (example - seawall): ______________ Type of fill below the Ordinary High Water Mark: ________________________________________ Does the shoreline or open water area have vegetation present? YES Open water fill beyond shoreline: (examples - boat well, underwater beach) Volume (cubic yds.): _________ Acres: _________ Type of fill: ____________________________________ Acres: _________ NO Page 1 of 5 American LegalNet, Inc. www.FormsWorkflow.com FOR STREAM IMPACT: (acceptable fill defined in instructions) Total linear feet of stream impact (examples - bank stabilization, bridge construction or culvert placement, seawall work): ______________ Type of fill below the Ordinary High Water Mark: _________________________________________ Proposed Start Date of work in the Stream (MM/DD/YY): _________ Channel width in feet (see instructions): _________ Volume (cubic yds.): _________ Proposed End Date of work in the Stream (MM/DD/YY): _________ Channel depth in feet (see instructions): _________ For stream crossings, type of structure proposed to be installed (examples: three-sided or four-sided culvert, bridge, pipe): ____________________________ For stream crossings, width of culvert structure/diameter of pipe to be installed (feet): _________ Open water fill that projects beyond the streambank: Length of culvert structure/pipe (feet): _________ Type of fill: ____________________________________ Acre(s) of impact: _________ FOR WETLAND IMPACT: (acceptable fill defined in instructions) Type of fill: _______________________________________ Acre(s) of impact: _________ emergent _________ scrub-shrub _________ forested SIGNATURE OF APPLICANT - STATEMENT OF AFFIRMATION I certify that I am familiar with the information contained in this notification form and, to the best of my knowledge and belief, such information is true and accurate. I certify that I have the authority to undertake and will undertake the activities exactly as described in this notification form. I am aware that there are penalties for submitting false information. I understand that any changes in project design subsequent to IDEM's granting of authorization to discharge to a Water of the U.S. are not authorized, and that I may be subject to civil and criminal penalties for proceeding without proper authorization. I agree to allow representatives of IDEM to enter and inspect the project site. I understand that the granting of other permits by local, state, or federal agencies does not release me from the requirement of obtaining the authorization requested herein before commencing the project. Signature of applicant: Date: Printed name of applicant: Title: (mm/dd/yyyy) Enclose copies of the following documents (ALL enclosures must be on 8.5” by 11” paper): Location map Mail this form and attachments via certified mail to: Drawings of existing site and proposed project Cross sections of proposed activities showing extent of fill waterward (for seawall, shoreline, and streambank stabilization impacts) Cross sections of proposed activities showing the bankfull width or Ordinary High Water Mark of the stream (for stream encapsulation impacts) At least three photos of the site, labeled Copy of wetland delineation report (for projects with wetland impacts) Indiana Department of Environmental Management Office of Water Quality Section 401 WQC/State Isolated Wetlands Program MC 65-42 IGCN 1255 100 North Senate Avenue Indianapolis, Indiana 46204-2251 Copies of all correspondence from the U.S. Army Corps of Engineers (for projects with wetland impacts) Copies of all correspondence from the Indiana Department of Natural Resources, Division of Nature Preserves Please note: 1. Send this form and the attachments via certified mail to IDEM at the above referenced address. IDEM will not notify you when this form is received. 2. IDEM will review this form and all attachments for completeness and accuracy. You will not be contacted by IDEM unless problems are identified with your application. IDEM may require additional information to verify that the project meets all conditions of the Regional General Permit and the Section 401 Water Quality Certification (WQC). If you are not contacted by IDEM within thirty (30) days of the date IDEM receives this notification form, your project is authorized, subject to the terms and conditions of the Section 401 Water Quality Certification and its conditions. You will not receive a written confirmation of authorization. 3. Read all the terms and conditions of this IDEM Regional General Permit Notification Form, including all U.S. Army Corps of Engineers and IDEM conditions. The terms and conditions of this general permit as instituted by IDEM are included as part of the instructions. Do not submit this notification form or commence work on the proposed project until you understand and are familiar with the limitations and restrictions of the IDEM Regional General Permit Notification Form. 4. Consult this webpage for more information: http://www.in.gov/idem/4870.htm Page 2 of 5 American LegalNet, Inc. www.FormsWorkflow.com TERMS AND CONDITIONS OF THE IDEM REGIONAL GENERAL PERMIT NOTIFICATION FORM 1. The applicant shall deposit any dredged material in a contained upland disposal area to prevent sediment runoff to any waterbody. The discharge of return water from upland contained disposal areas is not authorized by this general permit. Such discharges are regulated by the IDEM’s National Pollutant Discharge Elimination System (NPDES) Permitting Program. 2. This general permit does not authorize the discharge of storm water or the discharge of pollutants (such as sediment) associated with storm water. This general permit incorporates the conditions at 327 IAC 15-5-7 as general conditions of this Water Quality Certification (WQC). Compliance with the general permits at 327 IAC 15-5, or 327 IAC 15-6 (commonly referred to as a Rule 5 and Rule 6, respectively) is sufficient to demonstrate compliance with this condition of the WQC. 3. The permittee shall allow the commissioner or an authorized representative of the IDEM commissioner (including an authorized contractor), upon the presentation of credentials to: a) Enter upon the permittee’s property; b) Have access to and copy at reasonable times any records that must be kept under the conditions of these permits or this certification; c) Inspect, at reasonable times, any monitoring or operational equipment or method; collection, treatment, pollution management or discharge facility or device; practices required by this certification; and any mitigation site; and d) Sample or monitor any discharge of pollutants or any mitigation site. 4. This granting of WQC does not relieve the permittee from the responsibility of obtaining any other permits or authorizations that may be required for this project or related activities from the IDEM or any other agency or person. 5. This WQC does not: a) Authorize impacts or activities outside the scope of this certification; b) Authorize any injury to permittees or private property or invasion of other private rights, or any infringement of federal, state or local laws or regulations; c) Convey any property rights of any sort, or any exclusive privileges; d) Preempt any duty to obtain federal, state or local permits or authorizations required by law for the execution of the project or related activities; or e) Authorize changes in the plan design detailed in the notification form. 6. This general permit cannot authorize point source discharges of pollutants other than clean fill and uncontaminated dredged material. 7. This general permit cannot authorize activities on or in any of the State’s waters that have been designated by the Water Pollution Control Board as: salmonid waters (cold water streams), Outstanding State and/or National Resource Waters, and Exceptional Use waters. 8. This general permit cannot authorize activities on or in any critical wetland or critical special aquatic site. 9. This general permit cannot authorize activities on or in any non-salmonid stream between April 1 and June 30 unless the IDNR has granted a waiver for that activity. Contact information for the IDNR-Division of Fish and Wildlife is as follows: IDNR - Division of Fish and Wildlife Attn: Environmental Supervisor 402 W. Washington St., Room W273 Indianapolis, IN 46204 FAX: (317) 232-8150 10. You must submit, with this notification form, correspondence from the IDNR, Division of Nature Preserves, which states that no state endangered, threatened, or rare species is documented on a permanent or seasonal basis within a ½ (0.50) mile radius of the proposed project site by the Indiana Natural Heritage Data Center. Alternately, you may provide written documentation from the IDNR, Division of Nature Preserves, which states that the proposed activities will not constitute a violation of state laws protecting state endangered, threatened, or rare species if they are documented on a permanent or seasonal basis within a ½ (0.50) mile radius of the proposed project site. Additional information regarding how to request Indiana Natural Heritage Data, including fees, required information, and timeframes, is available at the following website: http://www.in.gov/dnr/3242.htm . Contact information for the IDNR-Division of Nature Preserves is as follows: IDNR - Division of Nature Preserves Attn: Ronald Hellmich 402 W. Washington St., Room W267 Indianapolis, IN 46204 Fax # 317-233-0133 11. This general permit does not authorize activities associated with the establishment of a mitigation bank. 12. Multiple impacts associated with the same project may be included on the same notification form. However, the cumulative acreage and linear footage of effect on Waters of the U.S. must be equal to or less than the most restrictive thresholds of the notification form. (Threshold limits of the notification form are listed in conditions 16-21.) For example, a road project may include several stream crossings. If the cumulative effect of these crossings is less than 0.10 acre and 300 linear feet and each crossing meets the other requirements of the notification form, then the activities can be authorized by the general permit. If, however, the cumulative effect of these crossings is greater than 0.10 acre or 300 linear feet, then the activities are not authorized by this general permit and an individual site-specific WQC is required. 13. In order to verify that a given project will qualify under the terms and conditions of this general permit, IDEM may require additional information from the applicant. If the applicant fails to provide any information requested by IDEM, then the project is not authorized. 14. The IDEM, for any project that qualifies under the terms and conditions of this general permit, may choose to require an individual site-specific WQC if it determines that the project would have more than minimal impacts to water quality, either viewed individually or collectively with other projects that may affect the same waterbody affected by the proposed project. 15. The permittee must submit the notification form at least 30 days prior to the commencement of the proposed activity. 16. The notification form is for activities proposing permanent impacts of one-tenth (0.10) of an acre or less of Waters of the U.S. Proposed impacts to Waters of the U.S. exceeding 0.10 acre cannot be authorized by this general permit and will require an individual site-specific WQC. Page 3 of 5 American LegalNet, Inc. www.FormsWorkflow.com 17. This notification form is for activities that will not permanently change the sinuosity, flow path, velocity, cross sectional area under the bank full elevation or the slope of any stream. Proposed activities that will permanently change the sinuosity, flow path, velocity, cross sectional area under the bank full elevation, or the slope of the stream cannot be authorized by this general permit and will require an individual site-specific WQC. 18. This notification form is for activities proposing permanent impacts to 300 linear feet or less of streambank or lake shoreline. Proposed impacts to streambanks or shorelines in excess of 300 linear feet cannot be authorized by this general permit and will require an individual site-specific WQC. 19. In the case of streambank stabilization activities or new lake and reservoir shoreline stabilization activities, the permittee must demonstrate that the streambank or shoreline in question is unstable. 20. Projects that propose stream encapsulation activities meet the following limitations: a) Must be for the purpose of constructing a crossing; b) Must not exceed 150 feet; c) The cross sectional area of the encapsulation is at least twenty percent (20%) larger than the bank full area of the stream immediately up and downstream of the encapsulation; d) The cross sectional area of the encapsulation is in the form of a single opening (double culverts are not authorized unless at least one of the culverts meets the cross sectional area requirement); e) Encapsulations either have no bottom (e.g., three sided culvert) or are twenty percent (20%) imbedded into the streambed (note that the area imbedded must be subtracted from the cross sectional area for the cross section area requirement above); and f) The slope of the bed within the encapsulation matches the slope of the bed both immediately upstream and downstream. Projects proposing an encapsulation activity that do not meet the aforementioned limitations cannot be authorized by this general permit and will require an individual site-specific WQC. 21. The activities proposed in the notification form cannot result in a permanent secondary effect to Waters of the U.S. (e.g., dredging, excavation, damming, creation of in-channel ponds) that, when combined with the primary effect, exceeds the area and length thresholds in previous conditions. Projects that result in permanent secondary effects to Waters of the U.S. that, when combined with the primary effect, exceeds the aforementioned area and length thresholds, cannot be authorized by this general permit and will require an individual site-specific WQC. Instructions for Completing the IDEM Regional General Permit Notification Form Please read these instructions carefully before completing the notification form. Sections labeled as mandatory must be completed accurately and completely in order for IDEM to process this notification form. IDEM will reject your notification form should you fail to complete all mandatory sections of the form. DO NOT use this form if your project will impact ANY isolated wetlands. Consult with IDEM staff to determine the correct application form for use with your project. If you have any questions or are unsure if your project qualifies for or requires this authorization, contact IDEM: Indiana Department of Environmental Management Office of Water Quality Section 401 Water Quality Certification/State Isolated Wetlands Program MC 65-42 IGCN 1255 100 North Senate Avenue Indianapolis, Indiana 46204-2251 Telephone: (317) 233-8488 Print clearly or type. Attach additional information on 8.5" x 11" sheets or folded 11” x17” sheets only BLOCK 1 – APPLICANT INFORMATION 1. MANDATORY: Provide the applicant's name, address, email address, and telephone number. Applicants MUST provide a contact name. 2. OPTIONAL: Provide the agent's address and telephone information (an agent is anyone representing the applicant on the project, such as an attorney or consultant). Applicants are not required to have an agent. This information should be included if a person other than the applicant is submitting the form and that person is designated as the contact point for questions regarding the proposed project. BLOCK 2 – PROJECT LOCATION MANDATORY: Complete all blocks within this section. Most information required in this section can be obtained from the United States Geological Survey (USGS) 7.5-Minute Series Topographic Quadrangle maps, your local Soil and Water Conservation District (SWCD) office, or similar computer desktop mapping software. An address or descriptive location must be provided in order to allow for compliance inspections of the project. BLOCK 3 – EXISTING CONDITIONS ON THE PROJECT SITE 1. MANDATORY: This section provides information on the types of aquatic resources present on the project site PRIOR TO any proposed impacts. Check the appropriate box as to whether or not lakes, streams, or wetlands are present on the site. For wetlands, provide the acreage of each wetland type – your wetland delineation report will state the acreage of each wetland type delineated on the site. Page 4 of 5 American LegalNet, Inc. www.FormsWorkflow.com 2. For wetlands, acreages and types must be confirmed with a wetland delineation conducted in accordance with the 1987 U.S. Corps of Engineers Wetland Delineation Manual. Please attach a copy of this delineation and letter of confirmation from the U.S. Corps of Engineers for all projects that will impact wetlands. Correspondence from the U.S. Army Corps of Engineers confirming that the Waters in question are regulated under the Clean Water Act must be provided. Any letter or email from the U.S. Army Corps of Engineers that describes the extent of Waters of the U.S. on the site will be considered acceptable by IDEM. Common examples include: a jurisdictional determination verification letter, a U.S. Army Corps of Engineers Public Notice, an “RGP pending” letter. BLOCK 4 – PROJECT IMPACTS 1. MANDATORY: Complete both “Activity Description” and “Purpose of Project” blocks within this section. Attach additional sheets if needed. Activity description refers to WHAT you intend to do – examples include filling a certain acreage of wetland, placing a certain quantity of riprap into a stream, constructing bridge piers, or installing a specific type of culvert. Project description refers to WHY you need to do this activity – to create a driveway, to stabilize a streambank, to install a bridge or culvert in a stream to access a site, to develop a site for commercial use, for example. 2. When calculating stream impacts, all areas that are affected by placement of fill, bank armoring, piping, installing culverts, excavation, or any other activity must be counted. Any proposed project involving the creation of dams or in-channel pools CANNOT use this notification form. 3. When calculating impacts, all areas within lakes, rivers, streams and the like must be counted. This includes areas under new bridge piers, footprints of underwater beaches, and footprints of boat ramps, as examples. 4. The Ordinary High Water Mark means that line on the shore of a waterbody established by the fluctuations of water and indicated by physical characteristics such as clear, natural line impressed on the bank, shelving, changes in the character of soil, natural destruction of terrestrial vegetation, the presence of litter and debris, or other appropriate means that consider the characteristics of the surrounding areas. 5. Channel width means the average distance from one bank of the stream to the other bank measured on the level at the bankfull stage elevation. IDEM will accept the Ordinary High Water Mark as a surrogate measurement for the bankfull stage elevation. Channel depth means the average distance from the bankfull stage elevation to the deepest part of the channel (thalwag). IDEM will accept the Ordinary High Water Mark as a surrogate measurement for the bankfull stage elevation. 6. Bankfull stage elevation means the elevation where any additional increase in stage elevation would result in water leaving the channel and entering the floodplain. The bankfull discharge is the same as the effective discharge. Determining the bankfull stage elevation from field indicators is also acceptable. The U.S. Environmental Protection Agency has provided tools for determining the bankfull stage elevation through the Watershed Assessment of River Stability and Sediment Supply (WARSSS) website at http://www.epa.gov/warsss/pla/box03.htm. IDEM will also accept the Ordinary High Water Mark as a surrogate measurement for the bankfull stage elevation. Note that IDEM does not require that a responsible party survey the bankfull stage elevation, but rather requires that width and depth measurements be taken relative to this elevation. 7. Acceptable fill material must be clean earthen fill that is free from any hazardous waste or regulated solid waste. Examples: clean earthen fill dirt, glacial stone, riprap, sand, freshly poured concrete. BLOCK 5 – SIGNATURE OF APPLICANT - STATEMENT OF AFFIRMATION MANDATORY: The name and signature must match the name of the applicant on the first page. Notification forms signed by any person other than the applicant will not be approved. NOTE - The listed supplemental information must be provided in order to verify that your project qualifies for the terms and conditions of this regional general permit. You may wish to hire a private environmental consultant to assist you with the completion of this form, assessing impact totals, and the creation of all required submittals (maps, photos, plans, cross-sections, IDNR and U.S. Army Corps of Engineers correspondence, etc.). Upon request, IDEM can provide you with a list of private environmental consultants that work in Indiana. If you are proposing impacts to wetlands, you will need to hire an environmental consultant to complete a wetland delineation for your property. Page 5 of 5 American LegalNet, Inc. www.FormsWorkflow.com