"Environmental Documentation Checklist" - New Hampshire

Environmental Documentation Checklist is a legal document that was released by the New Hampshire Department of Transportation - a government authority operating within New Hampshire.

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State of New Hampshire – Department of Transportation
ENVIRONMENTAL DOCUMENTATION
CHECKLIST
Excavation Permit, Encroachment Permit, and Driveway Permit Applicants are responsible for evaluating their project(s) for impacts to
the environment and verifying compliance with all applicable laws, rules, and regulations. This checklist is intended to provide a
summary of the environmental evaluation undertaken by the Applicant. In addition to completing this checklist, the Applicant is
responsible for securing all necessary environmental permits and approvals. Issuance of the Excavation Permit, Encroachment Permit,
or Driveway Permit is not an indication that the NH Department of Transportation (the Department) concurs with, or approves the
environmental evaluation performed by the Applicant or the Applicant’s designee(s). All Applicants must provide applicable
information and documentation associated with this checklist prior to issuance of the excavation or encroachment permit for the
Department’s record. Please check the box for each evaluation made and permit required to support work within the State ROW.
Disturbed Area (This includes, but may not be limited to any excavation and/or vegetation clearing)
 Provide total square footage of land disturbance: _______________
AOT Permit
 Consult NHDES, and/or visit the link provided, to determine if your project will require an AOT permit
(https://www.surveymonkey.com/r/?sm=u5SDvBCP0R2ThzxF3f2E%2fQ%3d%3d).
Provide the Alteration of Terrain
(AOT)Permit Number, if an AOT permit is required: ________________
 National Pollutant Discharge Elimination System (NPDES) Notice of Intent Tracking Number, if disturbing over 1 acre of
land: _______________
Cultural and/or Historic Resources
 Work conducted within 25 feet of a cemetery will comply with RSA 289:3.
 Work that impacts stone walls or other boundary markers will comply with RSA 472:6.
 Provide the New Hampshire Department of Historic Resources (DHR), Request for Project Review (RPR) file number
(http://www.nh.gov/nhdhr/review/rpr.htm) for projects that utilize any state or federal funds, or require a state or federal
permits (i.e. wetlands permit): _______________
Endangered Species - Attach to this checklist documentation of concurrence, as applicable, from the following agencies/groups:
 NH Natural Heritage Bureau (NHB), Use the
NHB DataCheck Tool
(https://www2.des.state.nh.us/nhb_datacheck/signin.aspx)
for online inquiries.
 US Fish & Wildlife Service, Use the ‘Information for Planning and Conservation’ (IPaC) tool
(http://ecos.fws.gov/ipac/
)
for online inquiries.
 NH Fish & Game Department, as necessary should there be concerns identified through either the IPaC tool, or NHB
review.
Floodplains/Floodways - Attach to this checklist documentation of concurrence from the following:
 NH Office of Energy and Planning (OEP) Floodplain Management Program, for a project that encroaches on regulatory
floodway; creates new obstructions in the 100 year floodplain; or alters any drainage patterns.
Wetlands/Water Quality – Permits must be obtained for any project that impacts wetlands/areas under the jurisdiction of RSA
482-A. If your project impacts wetlands or other RSA 482-A jurisdictional areas, complete the following
 NH Department of Environmental Services (NHDES), Wetlands Permit number: _______________
 Army Corps of Engineers, Wetlands Permit number: _______________
 NHDES Shoreland Permit number: _______________
Contamination -Perform a
NHDES OneStop
Web GIS search
(http://www2.des.state.nh.us/gis/onestop/register.asp
) to identify
any potential contamination and/or known remediation sites (active or closed) within 1,000 feet of the project, and/or impacts to
known asbestos disposal sites (ADSs).
 NHDES site number(s): _______________
Invasive Plant Species – Activities that disturb invasive plants or their root systems must comply with Prohibited Invasive Plant
Species Rules
(Agr 3800
), and
the Best Management Practices for the Control of Invasive and Noxious Plant Species
.
 Provide a map/plan showing locations of known invasive plant populations within the project area.
____________________________________________________________________________________________________________
I, the undersigned, take responsibility for the above reviews. To the best of my knowledge and ability, the information represented
in this document is accurate, and in conformance with applicable rules and regulations at the time of submission.
_____________________________________________________
___________________________________
Applicant Signature or Qualified Person
Date
Revised February 2021
State of New Hampshire – Department of Transportation
ENVIRONMENTAL DOCUMENTATION
CHECKLIST
Excavation Permit, Encroachment Permit, and Driveway Permit Applicants are responsible for evaluating their project(s) for impacts to
the environment and verifying compliance with all applicable laws, rules, and regulations. This checklist is intended to provide a
summary of the environmental evaluation undertaken by the Applicant. In addition to completing this checklist, the Applicant is
responsible for securing all necessary environmental permits and approvals. Issuance of the Excavation Permit, Encroachment Permit,
or Driveway Permit is not an indication that the NH Department of Transportation (the Department) concurs with, or approves the
environmental evaluation performed by the Applicant or the Applicant’s designee(s). All Applicants must provide applicable
information and documentation associated with this checklist prior to issuance of the excavation or encroachment permit for the
Department’s record. Please check the box for each evaluation made and permit required to support work within the State ROW.
Disturbed Area (This includes, but may not be limited to any excavation and/or vegetation clearing)
 Provide total square footage of land disturbance: _______________
AOT Permit
 Consult NHDES, and/or visit the link provided, to determine if your project will require an AOT permit
(https://www.surveymonkey.com/r/?sm=u5SDvBCP0R2ThzxF3f2E%2fQ%3d%3d).
Provide the Alteration of Terrain
(AOT)Permit Number, if an AOT permit is required: ________________
 National Pollutant Discharge Elimination System (NPDES) Notice of Intent Tracking Number, if disturbing over 1 acre of
land: _______________
Cultural and/or Historic Resources
 Work conducted within 25 feet of a cemetery will comply with RSA 289:3.
 Work that impacts stone walls or other boundary markers will comply with RSA 472:6.
 Provide the New Hampshire Department of Historic Resources (DHR), Request for Project Review (RPR) file number
(http://www.nh.gov/nhdhr/review/rpr.htm) for projects that utilize any state or federal funds, or require a state or federal
permits (i.e. wetlands permit): _______________
Endangered Species - Attach to this checklist documentation of concurrence, as applicable, from the following agencies/groups:
 NH Natural Heritage Bureau (NHB), Use the
NHB DataCheck Tool
(https://www2.des.state.nh.us/nhb_datacheck/signin.aspx)
for online inquiries.
 US Fish & Wildlife Service, Use the ‘Information for Planning and Conservation’ (IPaC) tool
(http://ecos.fws.gov/ipac/
)
for online inquiries.
 NH Fish & Game Department, as necessary should there be concerns identified through either the IPaC tool, or NHB
review.
Floodplains/Floodways - Attach to this checklist documentation of concurrence from the following:
 NH Office of Energy and Planning (OEP) Floodplain Management Program, for a project that encroaches on regulatory
floodway; creates new obstructions in the 100 year floodplain; or alters any drainage patterns.
Wetlands/Water Quality – Permits must be obtained for any project that impacts wetlands/areas under the jurisdiction of RSA
482-A. If your project impacts wetlands or other RSA 482-A jurisdictional areas, complete the following
 NH Department of Environmental Services (NHDES), Wetlands Permit number: _______________
 Army Corps of Engineers, Wetlands Permit number: _______________
 NHDES Shoreland Permit number: _______________
Contamination -Perform a
NHDES OneStop
Web GIS search
(http://www2.des.state.nh.us/gis/onestop/register.asp
) to identify
any potential contamination and/or known remediation sites (active or closed) within 1,000 feet of the project, and/or impacts to
known asbestos disposal sites (ADSs).
 NHDES site number(s): _______________
Invasive Plant Species – Activities that disturb invasive plants or their root systems must comply with Prohibited Invasive Plant
Species Rules
(Agr 3800
), and
the Best Management Practices for the Control of Invasive and Noxious Plant Species
.
 Provide a map/plan showing locations of known invasive plant populations within the project area.
____________________________________________________________________________________________________________
I, the undersigned, take responsibility for the above reviews. To the best of my knowledge and ability, the information represented
in this document is accurate, and in conformance with applicable rules and regulations at the time of submission.
_____________________________________________________
___________________________________
Applicant Signature or Qualified Person
Date
Revised February 2021
State of New Hampshire – Department of Transportation
ENVIRONMENTAL DOCUMENTATION
CHECKLIST
***Continued for Evaluation of MS4 Applicability***
MS4 Permit (applicable to projects over an acre within designated
MS4 communities
that meet all of the following criteria:)
 There is a point discharge from a catchment(s) greater than an acre. Non-point (sheet flow) does not need a permit.
 The point discharge enters a Water of the US. (navigable surface water or wetland)
 The point discharge comes from a Municipal Separate Sewer System (pipe or ditch, but not a culvert)
 The point discharge is in the Urbanize Area.
(If you have answered “Yes” to all of the criteria listed above you are subject to the requirements of an MS4 permit. For
additional guidance on EPA’s National Pollutant Discharge Elimination System, Small MS4 General Permit
(https://www.epa.gov/npdes-permits/new-hampshire-small-ms4-general-permit)
 A Technical Memo including a signed statement of compliance (by a qualified professional) in accordance with Appendix
B B.11.D of the MS4 permit and supporting plans documenting compliance with Part 2.3.6 of the MS4 permit has been
provided to DOT.
 DOT has accepted and approved the Technical Memo and Plans with documented concurrence that the materials provided
sufficiently meet the requirements of the MS4 permit.
Please refer to DOT internal guidance for a better understanding of what the Department will be looking for when the technical
memo and plans are provided. New Hampshire Department of Transportation 3rd Party Environmental Permit Guidance.
(If you have answered “No” your signature below is an acknowledgement that a qualified person has made the determination
that the project does not meet MS4 criteria and that a Technical Memo is not required.
-------------------------------------------------------------------------------
____________________________________
Qualified Person Signature
Date
Revised February 2021
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