20181662 Ver 1_RGL 16-01 Appendix 1_signed_3.15.18_20181207

Appendix 1 - REQUEST FOR CORPS JURISDICTIONAL DETERMINATION (JD)
To: District Name Here
•I am requesting a JD on property located at: _________________________________
(Street Address)
City/Township/Parish: ________________ County: _______________ State: ______
Acreage of Parcel/Review Area for JD: ___________
Section: ______ Township: _______ Range: _______
Latitude (decimal degrees):___________ Longitude (decimal degrees): ___________
(For linear projects, please include the center point of the proposed alignment.)
•Please attach a survey/plat map and vicinity map identifying location and review area for the JD.
•___ I currently own this property. ___ I plan to purchase this property.
___ I am an agent/consultant acting on behalf of the requestor.
___ Other (please explain): ____________________________________________________________.
•Reason for request: (check as many as applicable)
___ I intend to construct/develop a project or perform activities on this parcel which would be designed to
avoid all aquatic resources.
___ I intend to construct/develop a project or perform activities on this parcel which would be designed to
avoid all jurisdictional aquatic resources under Corps authority.
___ I intend to construct/develop a project or perform activities on this parcel which may require
authorization from the Corps, and the JD would be used to avoid and minimize impacts to jurisdictional
aquatic resources and as an initial step in a future permitting process.
___ I intend to construct/develop a project or perform activities on this parcel which may require authorization from
the Corps; this request is accompanied by my permit application and the JD is to be used in the permitting process.
___ I intend to construct/develop a project or perform activities in a navigable water of the U.S. which is
included on the district Section 10 list and/or is subject to the ebb and flow of the tide.
___ A Corps JD is required in order to obtain my local/state authorization.
___ I intend to contest jurisdiction over a particular aquatic resource and request the Corps confirm that
jurisdiction does/does not exist over the aquatic resource on the parcel.
___ I believe that the site may be comprised entirely of dry land.
___ Other: ___________________________________________________________
•Type of determination being requested:
___ I am requesting an approved JD.
___ I am requesting a preliminary JD.
___ I am requesting a “no permit required” letter as I believe my proposed activity is not regulated.
___ I am unclear as to which JD I would like to request and require additional information to inform my decision.
By signing below, you are indicating that you have the authority, or are acting as the duly authorized agent of a
person or entity with such authority, to and do hereby grant Corps personnel right of entry to legally access the
site if needed to perform the JD. Your signature shall be an affirmation that you possess the requisite property
rights to request a JD on the subject property.
*Signature: ____________________________________Date: _________________
•Typed or printed name: __________________________________________
Company name: __________________________________________
Address: __________________________________________
__________________________________________
Daytime phone no.: __________________________________________
Email address: __________________________________________
*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 Program of the U.S. Army Corps of Engineers; Final Rule for 33 CFR Parts 320-332.
Principal Purpose: The information that you provide will be used in evaluating your request to determine whether there are any aquatic resources within the project
area subject to federal jurisdiction under the regulatory authorities referenced above.
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. Your name and property location where federal jurisdiction is to be determined will be included in
the approved jurisdictional determination (AJD), which will be made available to the public on the District's website and on the Headquarters USACE website.
Disclosure: Submission of requested information is voluntary; however, if information is not provided, the request for an AJD cannot be evaluated nor can an AJD be
issued.