State Form 51821 "Application for Authorization to Discharge Dredged or Fill Material to Isolated Wetlands and/or Waters of the State" - Indiana

Form State51821 is a Indiana Department of Environmental Management form also known as the "Application For Authorization To Discharge Dredged Or Fill Material To Isolated Wetlands And/or Waters Of The State". The latest edition of the form was released in November 1, 2015 and is available for digital filing.

Download a PDF version of the Form State51821 down below or find it on Indiana Department of Environmental Management Forms website.

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Download State Form 51821 "Application for Authorization to Discharge Dredged or Fill Material to Isolated Wetlands and/or Waters of the State" - Indiana

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APPLICATION FOR AUTHORIZATION TO DISCHARGE DREDGED
OR FILL MATERIAL TO ISOLATED WETLANDS AND/OR
WATERS OF THE STATE
State Form 51821 (R2 / 11-15)
Indiana Department of Environmental Management
INSTRUCTIONS:
1. Read the instruction sheet before filling out this form.
2. You must complete all applicable sections of this form
1. Applicant Information
2. Agent Information
Name of Applicant
Name of Agent
Mailing address (Street/ PO Box/ Rural Route, City, State, ZIP Code)
Mailing address (Street/ PO Box/ Rural Route, City, State, ZIP Code)
Daytime Telephone Number
Daytime Telephone Number
Fax Number
Fax Number
E-mail address (optional)
E-mail address (optional)
Contact person (required)
Contact person
3. Project / Tract Location
County
Nearest city or town
U.S.G.S. Quadrangle map name (Topographic map)
Project street address (if applicable)
Quarter
Section
Township
Range
Type of aquatic resource(s) to be impacted (Attach Worksheet One.)
Project name or title (if applicable)
Other location descriptions or driving directions
4. Project Purpose and Description (Use additional sheet(s) if required.)
Has any construction been started?
Anticipated start date (month, day, year)
Yes
No
If yes, how much work is completed?
Purpose of project and overview of activities
Page 1 of 9
 
Reset Form
APPLICATION FOR AUTHORIZATION TO DISCHARGE DREDGED
OR FILL MATERIAL TO ISOLATED WETLANDS AND/OR
WATERS OF THE STATE
State Form 51821 (R2 / 11-15)
Indiana Department of Environmental Management
INSTRUCTIONS:
1. Read the instruction sheet before filling out this form.
2. You must complete all applicable sections of this form
1. Applicant Information
2. Agent Information
Name of Applicant
Name of Agent
Mailing address (Street/ PO Box/ Rural Route, City, State, ZIP Code)
Mailing address (Street/ PO Box/ Rural Route, City, State, ZIP Code)
Daytime Telephone Number
Daytime Telephone Number
Fax Number
Fax Number
E-mail address (optional)
E-mail address (optional)
Contact person (required)
Contact person
3. Project / Tract Location
County
Nearest city or town
U.S.G.S. Quadrangle map name (Topographic map)
Project street address (if applicable)
Quarter
Section
Township
Range
Type of aquatic resource(s) to be impacted (Attach Worksheet One.)
Project name or title (if applicable)
Other location descriptions or driving directions
4. Project Purpose and Description (Use additional sheet(s) if required.)
Has any construction been started?
Anticipated start date (month, day, year)
Yes
No
If yes, how much work is completed?
Purpose of project and overview of activities
Page 1 of 9
 
5. Avoidance, Minimization, and Mitigation Information: Applicants must answer all of the following questions
(Use additional sheet(s) if necessary - provide a detailed response to all applicable questions.)
A. For projects with Class II isolated wetlands –
1.
Is there a reasonable alternative to the proposed activity?
2.
Is the proposed activity reasonably necessary or appropriate?
B. For projects with Class III wetlands, adjacent wetlands, and/or streams, rivers, lakes or other water bodies –
1.
Is there a practicable alternative to the proposed activity?
2.
Have practicable and appropriate steps to minimize impacts to water resources been taken?
Describe all compensatory mitigation required for unavoidable impacts.
6. Drawing / Plan Requirements (Applicants must provide the following.)
a. Top/aerial/overhead views of the project site showing existing conditions and proposed construction.
b. Cross sectional view of areas of fill or alterations to streams and other waters.
c. North arrow, scale, property boundaries.
d. Include wetland delineation boundary (if applicable). Label all wetlands (jurisdictional, isolated and exempt) as I-1, I-2, I-3, etc. and the mitigation
areas as M-1, M-2, etc.
e. Location of all surface waters, including wetlands, erosion control measures, existing and proposed structures, fill and excavation locations,
disposal area for excavated material, including quantities, and wetland mitigation site (if applicable).
f. Approximate water depths and bottom configurations (if applicable).
7. Supplemental Application Materials (Applicants must provide the following.)
a. A wetland delineation of all wetlands on the project site (for projects with wetland impacts).
b. At least three photographs of the project site. Indicate the photo locations on the project plans.
c. If isolated wetlands are present, a letter from the Corps of Engineers verifying this statement.
d. Wetland mitigation plan and monitoring report.
e. Classification of all isolated wetlands on the tract (if isolated wetlands are present onsite).
f. Copies of all applicable local permits and/or resolutions pertaining to the project or tract.
g. Tract history (see instructions).
8. Additional information that MAY be required (IDEM will notify you if needed.)
a. Erosion control and/or storm water management plans.
b. Sediment analysis.
c. Species surveys for fish, mussels, plants and threatened or endangered species.
d. Stream habitat assessment.
e. Any other information IDEM deems necessary to review the proposed project.
Page 2 of 9
9. Permitting Requirements
a. Does this project require the issuance of a Department of the Army Section 404 Permit from the US Army Corps of Engineers?
Yes
No
If no, you do not need to answer Part b.
b. Have you applied for an Army Corps of Engineers Section 404 permit?
Yes
No
If yes, please supply the Corps of Engineers ID Number, the Corps of Engineers District, the project manager, and a copy of any correspondence with
the Corps. If no, contact the Army Corps of Engineers regarding the possible need for a permit application.
c. Have you applied for, received, or been denied a permit from the Department of Natural Resources for this project?
Yes
No
Please give the permit name, permit number, and date of application, issuance or denial.
d. Have you applied for, received, or been denied any other federal, state, or local permits, variances, licenses, or certifications for this project?
Yes
No
Please give the permit name, agency from which it was obtained, permit number, and date of issuance or denial.
10. Adjoining Property Owners and Addresses
List the names and addresses of landowners adjacent to the property on which your project is located and the names and addresses of other
persons (or entities) potentially affected by your project. Use additional sheet(s) if required.
Name
Name
Address (number and street)
Address (number and street)
City
State
ZIP Code
City
State
ZIP Code
Name
Name
Address (number and street)
Address (number and street)
City
State
ZIP Code
City
State
ZIP Code
Name
Name
Address (number and street)
Address (number and street)
City
State
ZIP Code
City
State
ZIP Code
Name
Name
Address (number and street)
Address (number and street)
City
State
ZIP Code
City
State
ZIP Code
Name
Name
Address (number and street)
Address (number and street)
City
State
ZIP Code
City
State
ZIP Code
Name
Name
Address (number and street)
Address (number and street)
City
State
ZIP Code
City
State
ZIP Code
 
Page 3 of 9
11. Signature - Statement of Affirmation
I certify that I am familiar with the information contained in this application 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 as described in this application. 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 state are not authorized and I may be subject to civil and criminal penalties for proceeding without proper authorization. I
agree to allow representatives of the 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.
Applicant’s Signature:
Date:
(mm/dd/yyyy)
Print Name:
Title:
Page 4 of 9
 
Worksheet – Summary of Onsite Water Resources and Project Impacts
A. Jurisdictional Wetlands (Existing Conditions)
Jurisdictional Wetlands (Proposed Impacts)
To be
Wetland Type
Size of wetland (acreage)
Acreage
Fill quantity (cys)
ATF
Impacted?
EM
SS
FO
Yes
No
EM
SS
FO
Yes
No
EM
SS
FO
Yes
No
EM
SS
FO
Yes
No
EM
SS
FO
Yes
No
EM
SS
FO
Yes
No
EM
SS
FO
Yes
No
Describe the type and composition of fill material to be placed in wetlands on the project site:
Describe the type and composition and quantity (cubic yards) of material proposed to be dredged or excavated from wetlands on the project site:
B. Isolated Wetlands (Existing Conditions)
Isolated Wetlands (Proposed Impacts)
To be
Wetland Class
Type
Size of wetland (acreage)
Acreage
Fill quantity (cys)
ATF
Impacted?
1
2
3
NF
F
Yes
No
1
2
3
NF
F
Yes
No
1
2
3
NF
F
Yes
No
1
2
3
NF
F
Yes
No
1
2
3
NF
F
Yes
No
1
2
3
NF
F
Yes
No
Describe the type and composition of fill material to be placed in isolated wetlands on the project site:
Describe the type and composition and quantity (cubic yards) of material proposed to be dredged or excavated from isolated wetlands on the project site:
C. Bridges and Stream Crossings - provide the following information for EACH structure (Use additional sheet(s) if required.)
Stream name
Description of impacts
Length of upstream bank impacts:
Left side:
Right side:
Length of downstream bank impacts:
Left side:
Right side:
Bank protection fill placed below the Ordinary High Water Mark:
Volume per running foot:
Bank protection fill placed below the Ordinary High Water Mark:
Area of coverage:
Page 5 of 9
 
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