20201589 Ver 1_B-5845_Eng_Form_4345_2012OCT_20220112

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U.S. ARMY CORPS OF ENGINEERS
APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT
33 CFR 325. The proponent agency is CECW-CO-R.
OMB APPROVAL NO. 0710-0003
EXPIRES: 28 FEBRUARY 2013

Public reporting for this collection of information is estimated to average 11 hours per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to Department of Defense,
Washington Headquarters, Executive Services and Communications Directorate, Information Management Division and to the Office of Management and
Budget, Paperwork Reduction Project (0710-0003). Respondents should be aware that notwithstanding any other provision of law, no person shall be
subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please DO NOT
RETURN your form to either of those addresses. Completed applications must be submitted to the District Engineer having jurisdiction over the location of
the proposed activity.
PRIVACY ACT STATEMENT
Authorities: Rivers and Harbors Act, Section 10, 33 USC 403; Clean Water Act, Section 404, 33 USC 1344; Marine Protection, Research, and Sanctuaries
Act, Section 103, 33 USC 1413; Regulatory Programs of the Corps of Engineers; Final Rule 33 CFR 320-332. Principal Purpose: Information provided on
this form will be used in evaluating the application for a permit. Routine Uses: This information may be shared with the Department of Justice and other
federal, state, and local government agencies, and the public and may be made available as part of a public notice as required by Federal law. Submission
of requested information is voluntary, however, if information is not provided the permit application cannot be evaluated nor can a permit be issued. One set
of original drawings or good reproducible copies which show the location and character of the proposed activity must be attached to this application (see
sample drawings and/or instructions) and be submitted to the District Engineer having jurisdiction over the location of the proposed activity. An application
that is not completed in full will be returned.
(ITEMS 1 THRU 4 TO BE FILLED BY THE CORPS)
1. APPLICATION NO.2. FIELD OFFICE CODE 3. DATE RECEIVED 4. DATE APPLICATION COMPLETE
(ITEMS BELOW TO BE FILLED BY APPLICANT)
5. APPLICANT'S NAME
First -Middle -Last -
Company -
E-mail Address -
6. APPLICANT'S ADDRESS:
Address-
City -State -Zip -Country -
7. APPLICANT'S PHONE NOs. w/AREA CODE
c. Faxb. Businessa. Residence
10. AGENTS PHONE NOs. w/AREA CODE
a. Residence b. Business c. Fax
8. AUTHORIZED AGENT'S NAME AND TITLE (agent is not required)
First -Middle -Last -
Company -
E-mail Address -
9. AGENT'S ADDRESS:
Address-
City -State -Zip -Country -
STATEMENT OF AUTHORIZATION
11. I hereby authorize, to act in my behalf as my agent in the processing of this application and to furnish, upon request,
supplemental information in support of this permit application.
SIGNATURE OF APPLICANT DATE
NAME, LOCATION, AND DESCRIPTION OF PROJECT OR ACTIVITY
12. PROJECT NAME OR TITLE (see instructions)
13. NAME OF WATERBODY, IF KNOWN (if applicable)14. PROJECT STREET ADDRESS (if applicable)
Address
City -State-Zip-15. LOCATION OF PROJECT
Latitude: ◦N Longitude: ◦W
16. OTHER LOCATION DESCRIPTIONS, IF KNOWN (see instructions)
State Tax Parcel ID Municipality
Section -Township -Range -
ENG FORM 4345, OCT 2012 PREVIOUS EDITIONS ARE OBSOLETE.
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18. Nature of Activity (Description of project, include all features)
19. Project Purpose (Describe the reason or purpose of the project, see instructions)
USE BLOCKS 20-23 IF DREDGED AND/OR FILL MATERIAL IS TO BE DISCHARGED
20. Reason(s) for Discharge
21. Type(s) of Material Being Discharged and the Amount of Each Type in Cubic Yards:
Type
Amount in Cubic Yards
Type
Amount in Cubic Yards
Type
Amount in Cubic Yards
22. Surface Area in Acres of Wetlands or Other Waters Filled (see instructions)
Acres
or
Linear Feet
23. Description of Avoidance, Minimization, and Compensation (see instructions)
ENG FORM 4345, OCT 2012
17. DIRECTIONS TO THE SITE
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25. Addresses of Adjoining Property Owners, Lessees, Etc., Whose Property Adjoins the Waterbody (if more than can be entered here, please attach a supplemental list).
a. Address-
Zip -State -City -
e. Address-
Zip -State -City -
d. Address-
Zip -State -City -
c. Address-
Zip -State -City -
b. Address-
City -State -Zip -
26. List of Other Certificates or Approvals/Denials received from other Federal, State, or Local Agencies for Work Described in This Application.
AGENCY TYPE APPROVAL*IDENTIFICATION
NUMBER DATE APPLIED DATE APPROVED DATE DENIED
SIGNATURE OF APPLICANT DATE SIGNATURE OF AGENT DATE
* Would include but is not restricted to zoning, building, and flood plain permits
27. Application is hereby made for permit or permits to authorize the work described in this application. I certify that this information in this application is
complete and accurate. I further certify that I possess the authority to undertake the work described herein or am acting as the duly authorized agent of the
applicant.
The Application must be signed by the person who desires to undertake the proposed activity (applicant) or it may be signed by a duly
authorized agent if the statement in block 11 has been filled out and signed.

18 U.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction of any department or agency of the United States
knowingly and willfully falsifies, conceals, or covers up any trick, scheme, or disguises a material fact or makes any false, fictitious or
fraudulent statements or representations or makes or uses any false writing or document knowing same to contain any false, fictitious or
fraudulent statements or entry, shall be fined not more than $10,000 or imprisoned not more than five years or both.
24. Is Any Portion of the Work Already Complete?Yes No IF YES, DESCRIBE THE COMPLETED WORK
ENG FORM 4345, OCT 2012