20210512 Ver 1_Revised Impact Table - PCN form - printed 7-1-21_20210701

C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections
❑ Wetlands
were completed below
for your project (check all that apply):
❑ Buffers ❑ Open Waters ❑ Pond Construction
X Streams — tributaries
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
Temporary (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 P
Culvert
UT to Beaverdam Creek
PER
Corps
3.6
28
S2 T
Excavation
UT to Beaverdam Creek
PER
Corps
3.6
20
S3 -
Choose one
-
-
S4 -
Choose one
-
-
S5 -
Choose one
-
-
S6 -
Choose one
-
-
3h. Total stream and tributary impacts
48
3i. Comments:
S1 permanently impacts 0.0036 acres of stream bed and S2 temporarily impacts 0.0017acres of stream bed.
Page 4 of 10
PCN Form — Version 1.4 January 2009