CM-2004-015.r'
APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT
/33 CFR 325) OMB APPROVAL NO. 0710-0003
xpires December 31, 2004
The Public burden for this collection of information is sestimated to average 10 hours per response, although the majority of applications should require
5 hours or less. This includes 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 this collection of
information, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Service Directorate of Information
Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302; and to the Office of Management and Budget,
Paperwork Reduction Project (0710-0003), Washington, DC 20503. 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.
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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, 33 USC 1413, Section 103. Principal Purpose: Information provided on this form will be used in evaluating the application
permit. Routine Uses: This information may be shared with the Department of Justice and other federal, state, and local government agencies. a
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
application (see sample drawings and instructions) and be submitted to the District Engineer havingp p°�o over they must be of attachedhe proposed this
activity. An application that is not completed in full will be returned. g jurisdiction location the
1. APPLICATION NO.
12.
(ITEMS 1 THRU 4 TO BE FILLED BY THE CORPS)
FIELD OFFICE CODE f 3. DATE RECEIVED
4. DATE APPLICATION COMPLETED
(ITEMS BELOW TO BE FILLED BY APPLICANT)
5. APPLICANT'S NAME 8. AUTHORIZED AGENT'S NAME AND TITLE (an agent is not required)
Larry Madsen, Project Manager
City of Round Rock, Public Works
6. APPLICANT'S ADDRESS
2008 Enterprise, Round Rock, Texas 78664
7.. APPLICANT'S PHONE NOS. W/AREA CODE
9. AGENT'S ADDRESS
same
11.
a. Residence
b. Business
512-218-5555 fax218-5563
10. AGENT'S PHONE NOS. W/AREA CODE
a. Residence
1 b. Business
same
hereby authorize,
STATEMENT OF AUTHORIZATION
to act in my behalf as my agent in the processing of this application and to
rurni , upon request, supplemental information in support of this permit application.
PPLICANT'S SIGNATURE
8Z7 -o4
DATE
NAME, LOCATION AND DESCRIPTION OF PROJECT OR ACTIVITY
12. PROJECT NAME OR TITLE (see instructions
Senior Activity Center
13. NAME OF WATERBODY. IF KNOWN (ifanniw.gb1, )
Lake Creek
15. LOCATION OF PROJECT
Williamson
COUNTY
Texas
STATE
15. OTHER LOCATION DESCRIPTIONS, IF KNOWN, (seemstructions)
4. PROJECT STREET ADDRESS (ifapp✓icabiel
301 West Bagdad Rd, Building 2
17. DIRECTIONS TO THE SITE
Take McNeil Rd exit east of IH -35, go one block to Blair Street then one block and go west on
Bagdad to end of street; crossing is one block south of street address on property.
ENG FORM 4345, Jul 97
EDITION OF FEB 94 IS OBSOLETE.
(Proponent: CECW-OR)
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18. Nature of Activity (Description of project, include al/ features)
One Creek Wastewater Utility Crossing and Two Storm Water Utility Headwalls (Regional General
Permit# CESWF-99-RGP-2)
19. Project Purpose (Describe the reason or purpose of the project, see instructions)
One wastewater line installation crossing creek to connect to the existing line on the south
creek bank. Two Water Quality Pond Outfalls for District storm drains.
20. Reason(s) for Discharge
Trench excavation of Creek bottom for pipe installation and installation of Rock Berm
downstream to limit erosion during construction. Spoil will be taken to upland staging pile
protected with Silt Fence. Pipe will be protected with concrete and native soil will be
backfilled above installation. Disturbed earth will be stabilized with hvdromulch.
21. Type(s) of Material Being Discharged and the Amount of Each Type in Cubic Yards
De -minimus silt.
USE BLOCKS 20-22 IF DREDGED AND/OR FILL MATERIAL IS TO BE DISCHARGED
22. Surface Area in Acres of Wetlands or Other Waters Filled (See instructions)
approximately 0.05 acres
23. Is Any Portion of the Work Already Complete? Yes No l IF YES. DESCRIBE THE COMPLETED WORK
Line clearing for cross section toporgraphic survey.
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).
ESA, Tejas, Inc., 555 IH -35 (Mail:Tax Site 6030,
Dora H. Robertson, 407 W Main (Mail: same)
John & Anne Giddings, 400 & 410 McNeil Rd.
City of Round Rock (Mail: 2008 Enterprise,
100 Dunbar St., Spartanburg, SC 29306)
(Mail: 941 Blue Spring Cir.,Round Rock, TX 78681)
Round Rock, Texas 78664)
25. List of Other Certifications or Approvals/Denials Received from other Federal, State or Local Agencies for Work Described in This Application.
AGENCY
TCEQ-EAPP
TCEQ-EAPP
TCEQ-TPDES
City of Roura
TYPE APPROVAL* IDENTIFICATION NUMBER
SewageCollec+oJ
WaterPolluticj
SWP3
Devel Permitu
*Would include but is not restricted to zoning, buildin in permits
26. Application is hereby made for a permit or
ap•'"cation is complete and accurate. 1
dul thorized agent of the applicant.
GNATURE OF APPLICANT DATE SIGNATURE OF AGENT
DATE APPLIED DATE APPROVED DATE DENIED
10/17/03
10/07/03
03/02/04
09/30/03
12/05/03
12/05/03
03/02/04
12/12/03
i
thorize the work described in this application. 1 certify that the information in this
that I possess the authority to undertake the work described herein or am acting as the
The app
authorize
on must be signed by the person who desires to undertake the proposed activity (applicant) or it may be signed by a duly
agent if the statement in block 11 has been filled out and signed.
DATE
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.
Instructions for Preparing a
Department of the Army Permit Application
Blocks 1 through 4. To be completed by Corps of Engineers.
Block 5. Applicant's Name. Enter the name of the responsible party or parties. If the responsible party is an agency,
company, corporation or other organization, indicate the responsible officer and title. If more than one party is
associated with the application, please attach a sheet with the necessary information marked Block 5.
Block 6. Address of Applicant. Please provide the full address of the party or parties responsible for the application.
If more space is needed, attach an extra sheet of paper marked Block 6.
Block 7. Applicant Telephone Number(s). Please provide the number where you can usually be reached during normal
business hours.
Blocks 8 through 11. To be completed if you choose to have an agent.
Block 8. Authorized Agent's Name and Title. Indicate name of individual or agency, designated by you, to represent
you in this process. An agent can be an attorney, builder, contractor, engineer or any other person or organization.
Note: An agent is not required.
Blocks 9 and 10. Agent's Address and Telephone Number. Please provide the complete mailing address of the agent,
along with the telephone number where he/she can be reached during normal business hours.
Block 11. Statement of Authorization. To be completed by applicant if an agent is to be employed.
Block 12. Proposed Project Name or Title. Please provide name identifying the proposed project (i.e., Landmark
Plaza, Burned Hills Subdivision or Edsall Commercial Center).
Block 13. Name of Waterbody. Please provide the name of any stream, lake, marsh or other waterway to be directly
impacted by the activity. If it is a minor (no name) stream, identify the waterbody the minor stream enters.
Block 14. Proposed Project Street Address. If the proposed project is located at a site having a street address (not a
box number), please enter here.
Block 15. Location of Proposed Project. Enter the county and state where the proposed project is located. if more
space is required, please attach a sheet with the necessary information marked Block 15.
Block 16. Other Location Descriptions. If available, provide the Section, Township and Range of the site and/or the
latitude and longitude. You may also provide description of the proposed project location, such as lot numbers, tract
numbers or you may choose to locate the proposed project site from a known point (such as the right descending
bank of Smith Creek, one mile down from the Highway 14 bridge). If a Targe river or stream, include the river mile of
the proposed project site if known.
Block 17. Directions to the Site. Provide directions to the site from a known location or landmark. Include highway
and street numbers as well as names. Also provide distances from known locations and any other information that
would assist in locating the site.
Block 18. Nature of Activity. Describe the overall activity or project. Give appropriate dimensions of structures such
as wing walls, dikes (identify the materials to be used in construction, as well as the methods by which the work is to
be done), or excavations (length, width, and height). Indicate whether discharge of dredged or fill material is involved.
Also, identify any structure to be constructed on a fill, piles or float supported platforms.
The written descriptions and illustrations are an important part of the application. Please describe, in detail, what you
wish to do. If more space is needed, attach an extra sheet of paper marked Block 18.
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