NH WETLANDS BUREAU PERMIT APPLICATION



Request for Stream Crossing Assessment

APPLICANT BUREAU/DISTRICT:

PATROL SECTION:

CONTACT NAME: DATE:

PROJECT NAME: STATE #:

BRIDGE #: FED #:

ADVERTISING DATE: CONSTRUCTION DATE:

PROJECT DESCRIPTION:

CROSSING LOCATION (Route and Town): STREAM NAME:

LAT/LONG AND/OR NORTHING AND EASTING:

CROSSING CONDITIONS:

IS THERE A HISTORY OF FLOODING AT THE CROSSING? Yes: No:

EXISTING PIPE TYPE, SIZE (length, width, diameter), AND CONDITION: 8’ dia x 188’ Long multiplate structure rusted invert.

REQUIRED ATTACHMENTS:

TOPO MAP INDICATING ACCURATE CROSSING LOCATION (1:24,000 scale)

PHOTOS OF CROSSING SHOWING INLET/OUTLET, UPSTREAM/DOWNSTREAM, & ROADWAY APROACHES

NOTES/COMMENTS: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

1. IS THE PROJECT LOCATED WITHIN ¼ MILE OF A NH DESIGNATED RIVER? Yes No

2. IS THE PROJECT LOCATED WITHIN A 100 yr FLOODPLAIN OR FLUVIAL EROSION HAZARD ZONE? Yes No

3. IS THE PROJECT LOCATED WITHIN A PRIME WETLAND/ 100 ft PRIME WETLAND BUFFER? Yes No

4. KNOWN WATER QUALITY IMPAIRMENTS LISTED IN 904.04(a)(3)? Yes No (If Yes List):_________________

5. KNOWN NHB RECORD(S) IN A JURISDICTIONAL AREA? Yes No (If Yes Attach Report)

WATERSHED SIZE IN ACRES:

CROSSING TIER:

If 2, 4, or 5 is YES, does applicable Agency have concerns with project? Yes No

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ENVIRONMENTAL INFORMATION (To be completed by BOE to determine Tier Classification)

ANSWER IF KNOWN OTHERWISE FOR BOE USE

FOR BOE USE ONLY

Request received: Anticipated Review: Actual Review:

CAD/D Entry: Returned to applicant:

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