Form TVA-17423 JOINT APPLICATION FORM - DEPARTMENT OF THE ARMY/TVA

OMB No. 3316-0060
Exp. Date 03/31/2007

JOINT APPLICATION FORM

Update with new
expiration date
The Department of the Army (DA) permit program is authorized by Section 10 of the Rivers and Harbors Act of 1899 and Section 404 of the Clean
Department of the Army/TVA

Water Act (P.L. 95-217). These laws require permits authorizing structures and work in or affecting navigable waters of the United States and
discharge of dredged or fill material into waters of the United States. Section 26a of the Tennessee Valley Authority Act, as amended, prohibits
construction, operation, or maintenance of any structure affecting navigation, flood control, or public lands or reservations across, along, or in
Tennessee River or any of its tributaries until plans for such construction, operation, and maintenance have been submitted to and approved by
Tennessee Valley Authority (TVA).

Name and Address of Applicant:

Name, Address, and Title of Authorized Agent:

Telephone Number:

Telephone Number:

Home
Office

the
the
the
the

Home
Office

Location where activity exists or will occur (include Stream Name and Mile, if known):

Application submitted to

DA

TVA

Date activity is proposed to commence:

Date activity is proposed to be completed:

Describe in detail the proposed activity, its purpose and intended use (private, public, commercial, or other). Describe structures to be
erected including those placed on fills, piles, or floating platforms. Also describe the type, composition, and quantity of materials to be
discharged or placed in the water; the means of conveyance; and the source of discharge or fill material. Please attach additional
sheets if needed.

Application is hereby made for approval of the activities described herein. I certify that I am familiar with the information contained in
this application, and that to the best of my knowledge and belief such information is true, complete, and accurate. I further certify that
I possess the authority to undertake the proposed activities. I agree that, if this application is approved by TVA, I will comply with
the attached terms and conditions and any special conditions that may be imposed by TVA at the time of approval. Please
note the U.S. Army Corps of Engineers may impose additional conditions or restrictions.

Date

Signature of Applicant

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 by any trick, scheme, or device 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 statement or entry, shall be
fined not more than $10,000 or imprisoned not more than five years, or both. The appropriate DA fee will be assessed when a permit is issued.

Names, addresses, and telephone numbers of adjoining property owners, lessees, etc., whose properties also join the waterway:

TVA 17423 [12-2006] Page 1 of 2

List of previous DA/TVA permits/approvals

DA

TVA
Permit Number

Date

Is any portion of the activity for which authorization is sought now complete?
Yes
No
(If “Yes” attach explanation)
Month and year the activity was completed:
. Indicate the existing work on the drawings.
List all approvals or certifications required by other federal, interstate, state, or local agencies for any structures, construction,
discharges, deposits, or other activities described in this application.
Issuing Agency

Type Approval

Identification No.

Date of Application

Date of Approval

Has any agency denied approval for the activity described herein or for any activity directly related to the activity described herein?
Yes
No
(If “Yes” attach explanation)
Project plans or drawings should accompany the application. These should be on paper suitable for reproduction no larger than 11 x
17 inches or contained on a 3-1/2 inch floppy computer disc in “dxf” format, and should be submitted to the appropriate TVA and U.S.
Army Corps of Engineers offices. An application that is not complete will be returned for additional information.

U.S.A.C.E. Offices

TVA Office Location

U.S. Army Corps of Engineers
Eastern Regulatory Field Office
Spring Cress Business Park
501 Adessa Blvd., Suite 250
Lenoir City, Tennessee 37771
(865) 986-7296

U.S. Army Corps of Engineers
Savannah District
The Plaza, Suite 130
1590 Adamson Parkway
Morrow, Georgia 30260-1763
(678) 422-2729

U.S. Army Corps of Engineers
Regulatory Branch
3701 Bell Road
Nashville, Tennessee 37214
(615) 369-7500

U.S. Army Corps of Engineers
Western Regulatory Field Office
2042 Beltline Road, SW, Bldg C, Suite 415
Decatur, Alabama 35602
(256) 350-5620

U.S. Army Corps of Engineers
Norfolk District
P.O. Box 338
Abingdon, Virginia 24212
(276) 623-5259

U.S. Army Corps of Engineers
Asheville Regulatory Field Office
151 Patton Avenue, Room 208
Asheville, North Carolina 28801-5006
(828) 271-4856

Tennessee Valley Authority

Needs to be
revised to the new
figure of 2 hours.

Privacy Act Statement
This information is being requested in accordance with Section 26a of the TVA Act as cited on the front page of this form. Disclosure of the information
requested is voluntary; however, failure to provide any required information or documents may result in a delay in processing your application or in your
being denied a Section 26a permit. An application that is not complete will be returned for additional information. TVA uses this information to assess
the impact of the proposed project on TVA programs and the environment and to determine if the project can be approved. Information in the
application is made a matter of public record through issuance of a public notice if warranted. Routine uses of this information include providing to
federal, state, or local agencies, and to consultants, contractors, etc., for use in program evaluations, studies, or other matters involving support services
to the program; to respond to a congressional inquiry concerning the application or Section 26a program; and for oversight or similar purposes,
corrective action, litigation or law enforcement.

Burden Estimate Statement
Public reporting burden for this collection of information is estimated to average 1.5 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 this collection of information, including suggestions for reducing this burden to Agency
Clearance Officer, Tennessee Valley Authority, 1101 Market Street, Chattanooga, Tennessee 37402; and to the Office of Management and Budget,
Paperwork Reduction Project (3316-0060), Washington, D.C. 20503.

TVA 17423 [12-2006] Page 2 of 2