20120534 Ver 1_More Info Received_20120601

20120 -0 34
C Proposed Impacts Inventory
1 Impacts Summary
la Which sections were completed below for your project (check all that apply)
❑ Wetlands ❑X Streams — tributaries ❑ Buffers ❑ Open Waters ❑ Pond Construction
2 Wetland Impacts
If there are wetland impacts proposed on the site then complete this question for each wetland area impacted
2a
Wetland impact
number
Permanent (P) or
Tem ora T
2b
Type of impact
2c
Type of wetland
2d
Forested
2e
Type of jurisdiction
Corps (404 10) or
DWQ (401 other)
2f
Area of
impact
(acres)
W1
Choose one
Choose one
Yes /No
W2
Choose one
Choose one
Yes /No
W3
Choose one
Choose one
Yes /No
W4
Choose one
Choose one
Yes /No
W5
Choose one
Choose one
Yes /No
W6
Choose one
Choose one
Yes /No
2g Total Wetland Impacts
2h Comments
3 Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site then complete this
question for all stream sites impacted
3a
Stream impact
number
Permanent (P) or
Temporary (T)
3b
Type of impact
3c
Stream name
3d
Perennial (PER) or
intermittent (INT)?
3e
Type of
jurisdiction
3f
Average
stream
width
(feet)
3g
Impact
length
(linear
feet)
S1 T
Water main crossing
UNNAMED TRIBUTARY
PER
DWQ
20
40
S2
Choose one
S3
Choose one
S4
Choose one
S5
Choose one
S6
Choose one
3h Total stream and tributary impacts
40
31 Comments
40 STREAM EXCAVATION = 40 LF
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PCN Form — Version 1 4 January 2009��—