Form DEP-ACGP-APP-001 "Connecticut Addendum Army Corps of Engineers General Permit (Ct Gp)" - Connecticut

What Is Form DEP-ACGP-APP-001?

This is a legal form that was released by the Connecticut Department of Energy and Environmental Protection - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 23, 2011;
  • The latest edition provided by the Connecticut Department of Energy and Environmental Protection;
  • 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 printable version of Form DEP-ACGP-APP-001 by clicking the link below or browse more documents and templates provided by the Connecticut Department of Energy and Environmental Protection.

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Download Form DEP-ACGP-APP-001 "Connecticut Addendum Army Corps of Engineers General Permit (Ct Gp)" - Connecticut

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DEEP/CPPU USE ONLY
App #:________________________________
Doc #:________________________________
Connecticut Addendum
Army Corps of Engineers
Check #:______________________________
General Permit State of Connecticut
______________________________________
Program: Programmatic General Permit
(CT GP)
NAE #:________________________________
DEEP #:_______________________________
Print or type unless otherwise noted.
Determinations:
Eligible Category 2
Eligible Category 1
Part I: Application Description
Individual Permit
Town where site is located:
Brief Description of Project:
Part II: Fee Information
There is no fee required at this time. The Department of Energy and Environmental Protection (DEEP) may
require an application fee to be submitted with this addendum at a later date.
Part III: Applicant Information
*If an applicant is a corporation, limited liability company, limited partnership, limited liability partnership, or a
statutory trust, it must be registered with the Secretary of State. If applicable, registrant’s name shall be stated
exactly as it is registered with the Secretary of State. This information can be accessed at CONCORD.
If an applicant is an individual, provide the legal name (include suffix) in the following format: First Name;
Middle Initial; Last Name; Suffix (Jr, Sr., II, III, etc.).
1. Applicant Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.
Fax:
Contact Person:
Title:
*E-Mail:
*By providing this e-mail address you are agreeing to receive official correspondence from the department,
at this electronic address, concerning the subject application. Please remember to check your security
settings to be sure you can receive e-mails from “ct.gov” addresses. Also, please notify the department if
your e-mail address changes.
DEP-ACGP-APP-001
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Rev. 12/23/11
DEEP/CPPU USE ONLY
App #:________________________________
Doc #:________________________________
Connecticut Addendum
Army Corps of Engineers
Check #:______________________________
General Permit State of Connecticut
______________________________________
Program: Programmatic General Permit
(CT GP)
NAE #:________________________________
DEEP #:_______________________________
Print or type unless otherwise noted.
Determinations:
Eligible Category 2
Eligible Category 1
Part I: Application Description
Individual Permit
Town where site is located:
Brief Description of Project:
Part II: Fee Information
There is no fee required at this time. The Department of Energy and Environmental Protection (DEEP) may
require an application fee to be submitted with this addendum at a later date.
Part III: Applicant Information
*If an applicant is a corporation, limited liability company, limited partnership, limited liability partnership, or a
statutory trust, it must be registered with the Secretary of State. If applicable, registrant’s name shall be stated
exactly as it is registered with the Secretary of State. This information can be accessed at CONCORD.
If an applicant is an individual, provide the legal name (include suffix) in the following format: First Name;
Middle Initial; Last Name; Suffix (Jr, Sr., II, III, etc.).
1. Applicant Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.
Fax:
Contact Person:
Title:
*E-Mail:
*By providing this e-mail address you are agreeing to receive official correspondence from the department,
at this electronic address, concerning the subject application. Please remember to check your security
settings to be sure you can receive e-mails from “ct.gov” addresses. Also, please notify the department if
your e-mail address changes.
DEP-ACGP-APP-001
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Rev. 12/23/11
Part III: Applicant Information (continued)
a) Registrant Type (check one):
individual
*business entity
federal agency
state agency
municipality
tribal
*If a business entity:
i)
check type:
corporation
limited liability company
limited partnership
limited liability partnership
statutory trust
Other:
ii) provide Secretary of the State business ID #:
This information can be accessed at
CONCORD
iii)
Check here if you are NOT registered with the SOTS.
Check here if any co-applicants. If so, attach additional sheet(s) with the required information as requested above.
b) Applicant's interest in property at which the proposed activity is to be located:
site owner
option holder
lessee
developer
easement holder
operator
other (specify):
Check here if there are co-applicants. If so, label and attach additional sheet(s) to this sheet with the
required information.
2. List primary contact for departmental correspondence and inquiries, if different than the applicant.
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.
Fax:
Contact Person:
Title:
E-Mail:
*By providing this e-mail address you are agreeing to receive official correspondence from the department,
at this electronic address, concerning the subject application. Please remember to check your security
settings to be sure you can receive e-mails from “ct.gov” addresses. Also, please notify the department if
your e-mail address changes.
3. Property Owner, if different than the applicant:
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.
Fax:
Contact Person:
Title:
E-Mail:
DEP-ACGP-APP-001
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Rev. 12/23/11
Part III: Applicant Information (continued)
4. List any engineer(s) or other consultant(s) employed or retained to assist in preparing the application or in
designing or constructing the activity.
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.
Fax:
Contact Person:
Title:
E-Mail:
Service Provided:
Check here if additional sheets are necessary, and label and attach them to this sheet.
Part IV: Site/Project Information
1. SITE NAME AND LOCATION
Is the name of the site the same as the name of the applicant?
Yes
No
Name of Site :
Street Address or Description of Location:
City/Town:
State:
Zip Code:
Latitude and longitude of the exact location of the proposed activity in degrees, minutes, and seconds or in
decimal degrees:
Latitude:
Longitude:
Method of determination (check one):
GPS
USGS Map
Other (please specify):
If a USGS Map was used, provide the quadrangle name:
2. COASTAL BOUNDARY: Is the activity which is the subject of this application located within the coastal
boundary as delineated on DEEP approved coastal boundary maps?
Yes
No
If yes, and this application is for a new authorization or a modification of an existing authorization where
the physical footprint of the subject activity is modified, you must submit a
Coastal Consistency Review
Form
(DEP-APP-004) with this completed application.
Information on the coastal boundary is available at the local town hall or on the “Coastal Boundary Map”
available at DEEP Maps and Publications (860-424-3555).
3. ENDANGERED OR THREATENED SPECIES: Is the project site located within an area identified as a
habitat for endangered, threatened or special concern species as identified on the "State and Federal
Listed Species and Natural Communities Map"?
Yes
No
Date of Map:
If yes, complete and submit a
Request for NDDB State Listed Species Review Form
(DEP-APP-007) to
the address specified on the form. Please note NDDB review generally takes 4 to 6 weeks and may
require additional documentation from the applicant.
The CT NDDB response must be submitted with this completed application.
For more information visit the DEEP website at
www.ct.gov/dep/nddbrequests
or call the NDDB at 860-424-
3011.
DEP-ACGP-APP-001
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Part IV: Project Information (continued)
4. AQUIFER PROTECTION AREAS: Is the site located within a town required to establish Aquifer
Protection Areas, as defined in section 22a-354a through 354bb of the General Statutes (CGS)?
Yes
No
To view the applicable list of towns and maps visit the DEEP website at
www.ct.gov/deep/aquiferprotection
If yes, is the site within an area identified on a Level A map?
Yes
No
If yes, is the site within an area identified on a Level B map?
Yes
No
If your site is on a Level A map, check the DEEP website,
Business and Industry Information
to determine
if your activity is required to be registered under the Aquifer Protection Area Program.
If your site is on a Level B map, no action is required at this time, however you may be required to register
under the Aquifer Protection Area Program in the future when the area is delineated as Level A.
5. CONSERVATION OR PRESERVATION RESTRICTION: Is the property subject to a conservation or
preservation restriction?
Yes
No
If Yes, proof of written notice of this registration to the holder of such restriction or a letter from the holder
of such restriction verifying that this registration is in compliance with the terms of the restriction, must be
submitted with this completed form.
6. Total area (in acres) within property boundaries:
7. Project Category: (please check all that apply)
Industrial Site Developmet
Condo/Apartment Complex
Commercial Site Development
Stream Restoration/Enhancement
Pond/Lake Dredging
Multiple Lot Residential Development
Fish/Wildlife Management (Government Agency)
Public Water Supply
Golf Course Development
Mine/Quarry
Individual Residential
Other (Describe below):
Part V: Environmental Information
1. Wetland Impact
a. Direct Impact
(Fill includes permanent & temporary):
sf
acres
b. Secondary/Indirect Impact:
sf
acres
c. Total Impact:
sf
acres
2. Waters/Waterways/Watercourses Impact
a. Direct Impact
(Fill includes permanent & temporary):
lf
sf
b. Secondary/Indirect Impact:
lf
sf
c. Total Impact:
lf
sf
DEP-ACGP-APP-001
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Rev. 12/23/11
Part V: Environmental Information (continued)
3. Do the following special wetland types occur on site?
Special Wetland
Yes
No
Total Area of
Area of Resource
Resource
Impacted
(SF)
(SF)
Vernal Pool
Fen
Bog
Cedar Swamp
Spruce Swamp
Calcareous Seepage Swamp
4. Channel Relocation/Restoration/Stabilization
Does the project include alterations to a perennial watercourse(s)?
Yes
No
If Yes, indicate all design features included in your project from the list below:
No
Design Features
Yes
Avoidance of barriers to fish movement
Formation of pools and riffles
Provisions for areas of sheltered flow (e.g., boulders, low check dams)
Preservation of stream bank vegetation and establishment of new vegetation
Use of clean natural bed materials of a suitable size
Indicate Design Flow for bank-full flow:
cfs
Indicate Frequency Recurrence (year):
Indicate Design Velocity for bank-full flow:
fps
Indicate Frequency Recurrence (year):
5. Floodplains
Yes
No
Is there a FEMA mapped floodplain for floodway on the site?
Are any excavations or permanent fill/structures proposed within the floodplain?
Are any excavations or permanent fill/structures proposed within the floodway?
Are any temporary stockpiles of fill or materials proposed within the floodplain?
Are any increases in the 100 year water surface elevation proposed?
If Yes, indicate maximum increase in feet:
Are any flooding increases proposed that would extend off the subject property?
If Yes, attach an explanation to this sheet.
If applicable, include with this form, hydraulic calculations including tabulated summary of results that demonstrate no
adverse impacts of any fill in a floodplain and which are in accordance with the guidance document entitled,
“Hydraulic Analysis Guidance Document”
(www.ct.gov/dep/lib/dep/Permits_and_Licenses/Land_Use_Permits/Inland_Water_Permits/iwrdhydraulicguidance.pdf)
DEP-ACGP-APP-001
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