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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