Form 102-4069 "Application for Certificate of Approval to Construct, Modify, Repair, Remove or Abandon a Dam" - Alaska

What Is Form 102-4069?

This is a legal form that was released by the Alaska Department of Natural Resources - a government authority operating within Alaska. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2018;
  • The latest edition provided by the Alaska Department of Natural Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 102-4069 by clicking the link below or browse more documents and templates provided by the Alaska Department of Natural Resources.

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Download Form 102-4069 "Application for Certificate of Approval to Construct, Modify, Repair, Remove or Abandon a Dam" - Alaska

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DIVISION OF MINING, LAND & WATER
DAM SAFETY AND CONSTRUCTION UNIT
th
550 West 7
Avenue, Suite 1020
Office Use Only
Action
Anchorage, AK 99501-3577
Date/Time Stamp
Construction
Removal
(907) 269-8636
Fax: 269-8904
Modification
Abandonment
Office Use Only
Repair
Other_______________
Receipt Type: DM
APPLICATION FOR CERTIFICATE OF APPROVAL
TO CONSTRUCT, MODIFY, REPAIR, REMOVE OR ABANDON A DAM
Instructions
Complete one application for each dam – Incomplete applications will not be accepted
Include cover letter with notice of intent [see 11 AAC 93.171(f)(1)(A)]
Attach additional required information [see 11 AAC 93.171 or 11 AAC 93.172]
Contact Dam Safety and Construction Unit for specific requirements
Submit non-refundable filing fee deposit – Minimum fee = $1,500 [see 11 AAC 05.260(c)(2)]
Dam Owner Information
______________________________________________________________
________________________________
Name of Dam and Reservoir
Identification Number (if assigned)
___________________________________________
__________________________
________________________
Owner Name
Authorized Representative
Title
________________________________________
________________________
____________
_____________
Mailing Address
City
State
Zip Code
___________________________
__________________________
____________________________________
Phone Number
Fax Number
E-mail Address
Engineer Information
__________________________________________________________________________________________________
Company
___________________________________________________________________________
___________________
Engineer of Record
Alaska Registration
________________________________________
________________________
____________
_______________
Mailing Address
City
State
Zip Code
______________________________
__________________________
_____________________________________
Phone Number
Fax Number
E-mail Address
Is dam located on anadromous fish stream?
Yes
No
Unknown
Has application been submitted for water rights?
Yes
No
Unknown
Is dam or reservoir located on state land?
Yes
No
Unknown
Is dam or reservoir located on federal land?
Yes
No
Unknown
102-4069, Rev. June 2018
Page 1 of 3
Print Form
DIVISION OF MINING, LAND & WATER
DAM SAFETY AND CONSTRUCTION UNIT
th
550 West 7
Avenue, Suite 1020
Office Use Only
Action
Anchorage, AK 99501-3577
Date/Time Stamp
Construction
Removal
(907) 269-8636
Fax: 269-8904
Modification
Abandonment
Office Use Only
Repair
Other_______________
Receipt Type: DM
APPLICATION FOR CERTIFICATE OF APPROVAL
TO CONSTRUCT, MODIFY, REPAIR, REMOVE OR ABANDON A DAM
Instructions
Complete one application for each dam – Incomplete applications will not be accepted
Include cover letter with notice of intent [see 11 AAC 93.171(f)(1)(A)]
Attach additional required information [see 11 AAC 93.171 or 11 AAC 93.172]
Contact Dam Safety and Construction Unit for specific requirements
Submit non-refundable filing fee deposit – Minimum fee = $1,500 [see 11 AAC 05.260(c)(2)]
Dam Owner Information
______________________________________________________________
________________________________
Name of Dam and Reservoir
Identification Number (if assigned)
___________________________________________
__________________________
________________________
Owner Name
Authorized Representative
Title
________________________________________
________________________
____________
_____________
Mailing Address
City
State
Zip Code
___________________________
__________________________
____________________________________
Phone Number
Fax Number
E-mail Address
Engineer Information
__________________________________________________________________________________________________
Company
___________________________________________________________________________
___________________
Engineer of Record
Alaska Registration
________________________________________
________________________
____________
_______________
Mailing Address
City
State
Zip Code
______________________________
__________________________
_____________________________________
Phone Number
Fax Number
E-mail Address
Is dam located on anadromous fish stream?
Yes
No
Unknown
Has application been submitted for water rights?
Yes
No
Unknown
Is dam or reservoir located on state land?
Yes
No
Unknown
Is dam or reservoir located on federal land?
Yes
No
Unknown
102-4069, Rev. June 2018
Page 1 of 3
Location and Land Owner Information
Water Body
River Mile
Tributary To
Region
Meridian
Township
Range
Section
USGS quad map
GPS Coordinates
Latitude
Longitude
_______________________________________
_____________________________________
_________________
Land Owner (for land under dam and reservoir)
Contact Name and Title
Phone Number
________________________________________
________________________
____________
_______________
Mailing Address
City
State
Zip Code
Dam Information
Proposed Hazard Potential Classification
Purpose of Dam
Dam Length (feet)
Type of Dam
(attach HPCJR Form)
Maximum Dam Height (feet) (dam crest to
Storage Capacity (acre-feet)
Surface Area (acres)
lowest point in original streambed)
at Spillway elevation
at Dam Crest elevation
Project Description
Application Submittals: Are the following required?
Feasibility Study
Yes
No
Water Rights Application
Yes
No
Siting Study
Yes
No
Design Scope Proposal
Yes
No
Financial Demonstration
Yes
No
Fee Deposit Calculation – Make checks payable to “Alaska Department of Natural Resources”
Total estimated project cost $____________________________
First $100,000
=
$____________________________
X
.02
=
$______________________
Next $400,000
=
$____________________________
X
.01
=
$______________________
Next $500,000
=
$____________________________
X
.005
=
$______________________
Over $1,000,000
=
$____________________________
X
.0025
=
$______________________
$______________________
Total Fee Deposit
=
________________________________________________________
___________________________________
Signature
Title
________________________________________________________
___________________________________
Name (please print)
Date
102-4069, Rev. June 2018
Page 2 of 3
AS 38.05.035(a) authorizes the director to decide what information is needed to process an application for the sale or use of state land and
resources. This information is made a part of the state public land records and becomes public information under AS 40.25.110 and 40.25.120
(unless the information qualifies for confidentiality under AS 38.05.035(a)(8) and confidentiality is requested, AS 43.05.230, or AS 45.48). Public
information is open to inspection by you or any member of the public. A person who is the subject of the information may challenge its
accuracy or completeness under AS 44.99.310, by giving a written description of the challenged information, the changes needed to correct it,
and a name and address where the person can be reached. False statements made in an application for a benefit are punishable under AS
11.56.210. In submitting this form, the applicant agrees with the Department to use “electronic” means to conduct “transactions” (as those
terms are used in the Uniform Electronic Transactions Act, AS 09.80.010 – AS 09.80.195) that relate to this form and that the Department need
not retain the original paper form of this record: the department may retain this record as an electronic record and destroy the original.
102-4069, Rev. June 2018
Page 3 of 3
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