20170940 Ver 1_REVISED_B4544PCN tables_20170803

C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections were completed below for your project (check all that apply):
� Wetlands � 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. 2b. 2c. 2d. 2e. 2f.
Wetland impact Type of jurisdiction
number — Type of impact Type of wetland Forested (Corps - 404, 10 Area of impact
Permanent (P) or (if known) DWQ — non-404, other) (acres)
Tem orar T
Fill/Mechaniz- � Yes � Corps
Site �/2 � P❑ T ed Clearing Riparian � No � pWQ 0.03
Site �/2 � P❑ T Excavation Riparian � Yes � Corps <0.01
❑ No ❑ DWQ
Fill/Mechaniz- � Yes � Corps
Site 2� P❑ T ed Clearing Riparian � No � pWQ 0.15
Fill/Mechaniz- � Yes � Corps
site 2�3 � P❑ T ed Clearing Riparian � No � DWQ 0.02
Fill/Mechaniz- � Yes � Corps
Site 3� P � T ed Clearing Riparian � No ❑ DWQ <0.01
Site 1❑ P❑ T ❑ Yes ❑ Corps
❑ No ❑ DWQ
0.20
2g. Total wetland impacts Permanent
2h. Comments: See Wetland Permit Impact Summary sheet for details. Hand clearing in riparian wetlands totals 0.04 ac.
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. 3b. 3c. 3d. 3e. 3f. 3g.
Stream impact Type of impact Stream name Perennial Type of Average Impact
number - (PER) or jurisdiction stream length (linear
Permanent (P) or intermittent (Corps - 404, 10 width feet)
Temporary (T) (INT)? DWQ — non-404, (feet)
other)
Site 1/2 ❑ P� T Fill Black River � PER � Corps 40 <0.01 ac
❑ INT ❑ DWQ
Site 2/3 � P � T Fill Black River � PER � Corps 40 21 If
❑ INT ❑ DWQ
Site 2/3 ❑ P� T Fill Black River � PER � Corps 40 0.02 ac.
❑ INT ❑ DWQ
Site ❑ P❑ T ❑ PER ❑ Corps
❑ INT ❑ DWQ
Site ❑ P❑ T ❑ PER ❑ Corps
❑ INT ❑ DWQ
Site ❑ P❑ T ❑ PER ❑ Corps
❑ INT ❑ DWQ
3h. Total stream and tributary impacts 21 ft P
0.02 ac.T

3i. Comments:
4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then individuall list all o en water im acts below.
4a. 4b. 4c. 4d. 4e.
Open water Name of
impact number — waterbody Type of impact Waterbody type Area of impact (acres)
Permanent (P) (if applicable)
or Temporary
T
02 � P❑ T Fill slope Borrow pit 0.05
02/3 � P � T Fill slope Swamp/Open <0.01
water
02 ❑ P� T Fill slope Borrow pit/swamp 0.02
02/3 ❑ P� T Fill slope Swamp/Open <0.01
water
4f. Total open water impacts 0.05 Permanent
0.02 Temporary
4g. Comments:
5. Pond or Lake Construction
If ond or lake construction ro osed, then com lete the chart below.
5a. 5b. 5c. 5d. 5e.
Wetland Impacts (acres) Stream Impacts (feet) Upland
Pond ID Proposed use or (acres)
number purpose of pond
Flooded Filled Excavated Flooded Filled Excavated Flooded
P1
P2
5f. Total
5g. Comments:
5h. Is a dam high hazard permit required?
❑ Yes ❑ No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction: