20221230 Ver 1_PCN Form Update Page 4 - Updated 11.1.22_20221101

C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections were completed below for your project (check all that apply):
❑X 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
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 P
Fill
Non -Tidal Freshwater Marsh
No
401/404
0.2
W2 P
Dredge
Non -Tidal Freshwater Marsh
No
401/404
0.1
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:
0.3
2h. Comments:
After -The -Fact Impacts.
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 Pigeon River
PER
401/404
3.7
160
S2 T
Culvert
UT to Pigeon River
PER
401/404
3.7
20
S3
Choose one
-
S4
Choose one
S5
Choose one
S6
Choose one
3h. Total stream and tributary impacts
180
3i. Comments:
After -The -Fact Impacts. The 20 feet of culvert will be removed and restored to existing grade. The permanent stream impact area is 0.016 acres.
Page 4 of 10
PCN Form — Version 1.4 January 2009