3150-PM-BWEW0551
Form
Rev. 10/2013
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WATERWAYS ENGINEERING AND WETLANDS
DEP USE ONLY
Received Date
Permit # -
CHAPTER 106
FLOODPLAIN MANAGEMENT
SITE RESTORATION PERMIT
APPLICATION and AUTHORIZATION
SECTION A. PERMITTEE
Name of Municipality and County
DEP Client ID (If known)
Mailing Address
City
Telephone No.
Alternate Telephone No.
(
(
)
State
Zip
Contact Name & Email address:
)
SECTION B. PROJECT DATA (GENERAL DESCRIPTION OF WORK RELATED ACTIVITIES)
SECTION C. SINGLE AND MULTIPLE SITE LOCATION DATA
CHAPTER 106: SITE/PROPERTY INVENTORY
List the information below for each Project Site and Individual Property
* Sites can contain multiple individual properties and multiple sites can be included in a single project. List below each individual property that is
located within or partially within the 100-year floodplain, attach additional sheets (as required) providing the same information requested in the chart.
Individual
Property
Number
Property Name &
Physical Address
Size of
Property
(ac.)
Earth
Disturbance
(ac.)
Name of USGS
Quadrangle Map
1
2
3
4
5
6
7
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Floodplain Map
No.
Latitude
Longitude
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Form
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SECTION D. FLOODPLAIN PROJECT CHECKLIST
Note: Individual projects that are located entirely outside the 100-year floodplain are not required to obtain this
Chapter 106 authorization but are required to comply with Conditions E.2., E.3., and E.5. through E.8. and E.10.
YES
NO
1. Will any work be done outside the 100-year floodplain, If yes, see Section E.2.
2. Will any work be done within the watercourse or floodway? If yes, see Section E. 4.
3. Will any work be done within a wetland? If yes, See Section E.4.
4. Will any structures (retaining walls, outfall pipes, etc.) located within the watercourse,
wetland or floodway be left in place? If yes, see Section E. 9.
5. Will any earth disturbance activity on any single property be 1 acre or more? If yes, see
Section E.3.
SECTION E. FLOODPLAIN PERMIT CONDITIONS
1. Contact the
County Conservation District at telephone number
prior to commencement of work.
2. An Erosion and Sediment Control Plan, meeting the requirements of Chapter 102, must be implemented during
and after construction and be available on the project site. Upon final completion permanent stabilization is
required.
3. Earth disturbance activities of 1 acre or more for each individual property will require a separate NPDES
stormwater construction permit.
4. All work must be conducted within the 100-year floodplain. Where work other than removal of a water obstruction
or encroachment within a watercourse or floodway, wetland or other body of water is required; a separate
Chapter 105 Authorization must be obtained.
5. All excavated material must be disposed of beyond the limits of the 100-year floodplain, nor placed in any
wetlands.
6. Waste materials, scrap, or construction, demolition materials may not be disposed of in any watercourse,
floodway or body of water but shall be collected, stored, and disposed of in accordance with the Solid Waste
Management Act (35 P.S. §§ 6018.101-6018.1003), the Municipal Waste, Planning, Recycling and Waste
Reduction Act (53 P.S. §§ 4000.101-4000.1904), the Clean Streams Law (35 P.S. §§ 691.1-691.1001) and
related rules and regulations.
7. Secure all other approvals that may be necessary under other Federal, State or local regulations.
8. This approval does not give any property rights, either in real estate or material, nor any exclusive privileges, nor
shall be construed to grant or confer any right, title, easement, or interest, in, to, or over any land belonging to the
Commonwealth of Pennsylvania; neither does it authorize any injury to private property or invasion of private
rights.
9. Property owners are required to obtain a Chapter 105 permit to maintain a water obstruction or encroachment not
removed from the watercourse, wetland and floodway as a result of this activity. Contact the DEP Regional Office
for assistance.
10. SPECIAL CONDITIONS as follows:
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3150-PM-BWEW0551
Form
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SECTION F. PROJECT SITE PLAN CHECKLIST
Provide the following information for each project site plan. Incomplete submissions will be returned
Project Name:
Stream Name:
Stream Limits and Flow Direction
Copy of Floodplain Map
Copy of U.S.G.S Quadrangle Location Map on
8 ½ x 11 sheet of paper
Limits of Earth Disturbance Associated with this
Activity
Location of Property Lines Relative to the Project
Existing Utilities
Existing Buildings, Roadways, Other Structures
Existing Elevations including 100 year Flood
Elevation
Other Waters (i.e. pond, lakes, wetlands)
SECTION G. CERTIFICATION
I certify under penalty of law that the information provided in this permit registration is true and correct to the best of
my knowledge and information and that I possess the authority to undertake the proposed action. I am aware that
there are significant penalties for submitting false information, including the possibility of fine and imprisonment for
knowing violations. (If any of the information and/or plans is found to be in error, falsified, and / or incomplete, this
authorization/verification may be subject to modification, suspension, or revocation in accordance with applicable
regulations.)
Signature of Permittee
Date
(Chief Officer / Responsible Official)
Type or Print Name/Title
SEAL AFFIXED
AN ACKNOWLEDGED COPY OF THIS PERMIT AND EROSION AND SEDIMENT CONTROL PLAN MUST BE
AVAILABLE AT THE PROJECT SITE AT ALL TIME DURING CONSTRUCTION.
SECTION H. SIGNATURE OF DEP REVIEWER/MANAGER
Reviewer’s Signature authorizing acknowledgment of authorization to use.
DEP Reviewer’s Signature
Date
Reviewer’s Type or Printed Name
Contact Phone Number
DEP Manager Signature
Manager’s Type or Printed Name
Commonwealth of Pennsylvania email address
Date
Contact Phone Number
Commonwealth of Pennsylvania email address
SECTION 106.14(a)&(b) OF THE FLOODPLAIN MANAGEMENT REGULATIONS REQUIRES A NOTICE OF A
COMPLETE APPLICATION IN THE PENNSYLVANIA BULLETIN. THE PERMIT SHALL BECOME EFFECTIVE IN 60
DAYS FROM DATE OF RECEIPT OF A COMPLETE APPLICATION UNLESS DISAPPROVED BY THE DEPARTMENT.
Complete Application Date
Permit Effective Date
PERMIT EXPIRES 5 YEARS FROM THE EFFECTIVE DATE UNLESS OTHERWISE EXTENDED IN
WRITING BY THE DEPARTMENT.
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DEPARTMENT OF ENVIRONMENTAL PROTECTION
REGIONAL OFFICES
Waterway and Wetlands Section
County Responsibility
(Activities not associated with oil and gas activities)
Northcentral Regional Office
208 W. Third Street, Suite 101
Williamsport, PA 17701
(570) 327-3574
Bradford, Cameron, Centre, Clearfield, Clinton,
Columbia, Lycoming, Montour, Northumberland,
Potter, Snyder, Sullivan, Tioga and Union
Northeast Regional Office
2 Public Square
Wilkes-Barre, PA 18711-0790
(570) 826-2511
Carbon, Lackawanna, Lehigh, Luzerne, Monroe,
Northampton, Pike, Schuylkill, Susquehanna,
Wayne and Wyoming
Northwest Regional Office
230 Chestnut Street
Meadville, PA 16335
(814) 332-6984
Butler, Clarion, Crawford, Elk, Erie, Forest,
Jefferson, Lawrence, McKean, Mercer,
Venango and Warren
Southcentral Regional Office
909 Elmerton Avenue, Second Floor
Harrisburg, PA 17110
(717) 705-4707
Adams, Bedford, Berks, Blair, Cumberland,
Dauphin, Franklin, Fulton, Huntingdon, Juniata,
Lancaster, Lebanon, Mifflin, Perry and York
Southeast Regional Office
2 East Main Street
Norristown, PA 19401-4915
(484) 250-5970
Bucks, Chester, Delaware, Montgomery and
Philadelphia
Southwest Regional Office
400 Waterfront Drive
Pittsburgh, PA 15222-4745
(412) 442-4000
Allegheny, Armstrong, Beaver, Cambria,
Fayette, Greene, Indiana, Somerset,
Washington and Westmoreland
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