Free 42946.pdf - Indiana

PERMIT APPLICATION FOR CONSTRUCTION
State Form 42946 (R6 / 2-05)

Approved by the State Board of Accounts, 2005

Mail To: Department of Natural Resources Division of Water 402 West Washington Street, Room W264 Indianapolis, Indiana 46204-2641 Telephone Number: (317) 232-4160 Toll Free: 1-877-928-3755 Fax Number: (317) 233-4579 www.IN.gov/dnr/water

Based on the "Permit Application Assistance Manual", I am submitting this application to perform work under: Permit Type Application Fee Permit Type Application Fee $ 50.00 $ 100.00

IC 14-26-2 Lake Preservation Act $ 100.00 IC 14-29-3 Sand and Gravel Permits Act IC 14-26-5 Lowering of the Ten Acre Lake Act $ 25.00 IC 14-29-4 Construction of Channels Act IC 14-29-1 Navigable Waterways Act No Fee IC 14-28-1 Flood Control Act, (select one of the following:) Excavation, fill, or non-residential construction in a floodway Residential reconstruction in a floodway, other than the Ohio River floodway Residential construction, or reconstruction, in the Ohio River floodway

$ 200.00 $ 50.00 $ 10.00

PLEASE TYPE OR PRINT
1. APPLICANT INFORMATION

Name of Applicant Applicant Mailing Address
Street, P.O. Box or Rural Route

Name of Contact Person

City

State

ZIP Code

Contact Information: Daytime Tele. # (
2. AGENT INFORMATION

)

Fax # (

)

E-mail Address

Name of Agent Agent Mailing Address
Street, P.O. Box or Rural Route

Name of Contact Person Person
City ) State ZIP Code

Contact Information: Daytime Tele. # (
3. PROPERTY OWNER INFORMATION

)

Fax # (

E-mail Address

Name of Property Owner Property Owner Mailing Address
Street, P.O. Box or Rural Route

Name of Contact Person Person
City State ZIP Code

Contact Information: Daytime Tele. # (
.

)

Fax # ( Purchaser

)

E-mail Address Other

Relationship of applicant to property:
4. PUBLIC NOTICE

Owner

Lessee

(See Permit Application Assistance Manual)
st

Complete and submit SF # 52086 titled "Adjacent Property Owners Listing - Form N-4: Affirmation of personal service, 1 class mail service, or certified mail service 5. PROJECT DESCRIPTION 5.1 Description Narrative: (See Permit Application Assistance Manual)

____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

6. PROJECT LOCATION 6-1 Location Narrative: (See Permit Application Assistance Manual) Stream/Lake Name:

6-2 Driving Directions: (See Permit Application Assistance Manual)

6-3 Special Information: (See Permit Application Assistance Manual)

6-4 Project Location Map: (See Permit Application Assistance Manual) 6-5 Project Site Map: (See Permit Application Assistance Manual) 7. DISTURBED AREA DRAWING 7-1 Drawing Requirements: (See Permit Application Assistance Manual) 8. PROJECT PHOTOGRAPHS 8-1 Images: (See Permit Application Assistance Manual) 8-2 Photo Orientation Map: (See Permit Application Assistance Manual) 8-3 Photo Documentation: (See Permit Application Assistance Manual) 9. RELATED PROJECT INFORMATION Department of Natural Resources Administrative Cause # Floodplain Analysis/Regulatory Assessment # Related Application(s) # Violation # Early Coordination # Exemption #

Department of Environmental Management Section 401 # Corps of Engineers Public Notice # Section 404 Application # Section 10 Application #

10. STATEMENT OF AFFIRMATION I hereby swear or affirm, under the penalties for perjury, that the information submitted herewith is to the best of my knowledge and belief, true, accurate and complete. I further certify that I possess the authority to undertake the project. I hereby grant to the Department of Natural Resources, the right to enter the above-described location to inspect the work.

Signature of Applicant or Authorized Agent (REQUIRED)

Date (month, day, year)

11. REGULATORY FEES 11-1 Regulatory Fees Submitted: (See Permit Application Assistance Manual) 11-3 Payment Method: (See Permit Application Assistance Manual) REQUIREMENT FOR ADDITIONAL INFORMATION AND PERMITS Application made to and approval granted by the Department of Natural Resources does not in any way relieve the applicant of the necessity of securing easements or other property rights, permits and approvals from affected property owners and other local, state, and federal agencies.