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 20-22 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
22. Surface Area in Acres of Wetlands or Other Waters Filled
(see instructions)
23. Is Any Portion of the Work Already Complete? Yes
No
IF YES, DESCRIBE THE COMPLETED WORK
24. Addresses of Adjoining Property Owners, Lessees, Etc., Whose Property Adjoins the Waterbody (If more than can be entered here,
please attach a supplemental list).
25. List of Other Certifications 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
26. Application is hereby made for a permit or permits to authorize the work described in this application. I certify that the 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.
DATE
SIGNATURE OF APPLICANT
SIGNATURE OF AGENT
DATE
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 ,000 or imprisoned not more than five years or both.