EFTA00621699.pdf

U.S. ARMY CORPS OF ENGINEERS APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT 33 CFR 325. The proponent agency is CECW•CO.R. Form Approved - OMB No. 0710.0003 Expires: 30-SEPTEMBER-2015 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 par 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 'MAU 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. APPLICANTS NAME First • Erika Middle - A. Company • Great St. Jim, LLC Lost - Kellerhals 8. AUTHORIZED AGENT'S NAME AND TITLE (agent is not required) First • Amy Middle • Claire Last - Dempsey Company • Bioimpact, Inc. E-mail Address • bioimpact@islands.vi E-mail Address • 6. APPLICANTS ADDRESS: Address- 9053 Estate Thomas Suite 101 City - St. Thomas State • VI ZIP • 0802 Country • USA 9. AGENTS ADDRESS: Address- ■. Box 132, Kingshill City • St. Croix State - VI Zip • 0085 Country - USA 7. APPLICANT'S PHONE NOs. w/AREA CODE a. Residence b. Business c. Fax (340) 779-2564 (888) 316-9269 10. AGENTS PHONE NOs. w/AREA CODE a. Residence b. Business c. Fax 340 773 5881 340 690-8445 340 718.3800 STATEMENT OF AUTHORIZATION 11. I hereby authorize, Amy Claire Dempsey 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) Dock Maintenance existing Dock GSJ, Placement of RO intake line under dock 13. NAME OF WATERBODY, IF KNOWN (if applicable) Pillsbury Sound - Great St. James Northern Bay 14. PROJECT STREET ADDRESS (if applicable) Address Parcel A City • Great St. James Slate - VI Zip- 15. LOCATION OF PROJECT Latitude: 41 18° 18.745' Longitude: ,W 64° 49.589 16. OTHER LOCATION DESCRIPTIONS, IF KNOWN (see instructions) State Tax Parcel ID 109801010100 Municipality Section . Great St. James Township - Range - ENG FORM 4345, DEC 2014 PREVIOUS EDITIONS ARE OBSOLETE. Page I of 3 EFTA00621699 17. DIRECTIONS TO THE SITE From Red Hook, St. Thomas proceed south in Pillsbury Sound to Great St. James, the dock is located in the northeast bay. 18. Nature of Activity (Description of project, include all features) Great St. Jim, LLC would like to conduct dock maintenance on the existing dock. They would like to replace the decking which has become splintered and replace the cleats and other hardware on the dock. They would also like to place a reverse osmosis intake line under the dock. The 6" HDPE line would be placed on the pile caps and a wedge wire intake would be suspended 2' under the the terminus of the dock. 19. Project Purpose (Describe the reason or purpose of the project, see instructions) To maintain the existing dock, and to provide for a seawater intake for an Reverse Osmosis plant to supply water to the island. USE BLOCKS 20-23 IF DREDGED AND OR FILL MATERIAL IS TO BE DISCHARGED 20. Reason(s) for Discharge No discharge is proposed. 21. Type(s) of Material Being Discharged and the Amount of Each Type in Cubic Yards: Type Type Type Amount in Cubic Yards Amount in Cubic Yards Amount in Cubic Yards 0 0 0 22. Surface Area in Acres of Wetlands or Other Waters Filled (see instructions) Acres 0 or Linear Feet () 23. Description of Avoidance, Minimization, and Compensation (see instructions) The proposal is the maintenance of an existing dock and the suspension of the intake line under the dock. No sea floor disturbance is proposed. The project avoids all impact to the marine environment. No compensation is proposed. ENG FORM 4345. DEC 2014 Page 2 of 3 EFTA00621700 24. Is Any Portion of the Work Already Complete? Eves Dik• IF YES, DESCRIBE THE COMPLETED WORK This is the maintenance of a existing dock. There was a intake under the dock, but that has been removed. 25. Addresses of Adjoining Property Owners, Lessees, Etc.. Whose Property Adjoins the Waterbody (il more roan can be calved here. pies° anach a supplernenlal 1st). a. Address- Great St. Jim, LLC, do Erika A. Kellerhals, 9053 Estate Thomas Suite 101 City • St. Thomas State - Vi ZiP • 00802 b. Address- City • State - Zip - c. Address. City • State - Zip - d. Address- City • State • Zip - a. Address- City • State • Zip - 26. Ust of Other Certificates or Approvals/Denials received from other Federal, State. or Local Agencies for Work Described in This Application. AGENCY TYPE APPROVAL' IDENTIFICATION DATE APPLIED DATE APPROVED DATE DENIED NUMBER DPNR/CZM Minor Modification CZT-39-87W concurrent for mod original 10/31/1988 • 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. SIGNATURE OF APPLICANT DATE 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 $10,000 or imprisoned not more than five years or both. ENG FORM 4345 DEC 2014 Page 3 of 3 EFTA00621701