Form 086-0-27D Coastal Structures Form

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

O.M.B. NO. 1660-0016
Expires December 31, 2010

COASTAL STRUCTURES FORM

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 1 hour per response . The burden estimate includes the time for
reviewing instructions, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing , and
submitting the form. You are not required to respond to this collection of information unless a valid OMB control number appears in the
upper right corner of this form . Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this
burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C
Street, SW, Washington , DC, 20472, Paperwork Reduction Project (1660-0016) . Submission of the form is required to obtain or retain
benefits under the National Flood Insurance Program. Please do not send your completed s urvey to the above address.
Flood ing Source:

--------------------------------------------------------------------------------­

Note : Fill out one form for each flood ing source stud ied .

A. BACKGROUND
1. Name of structures (if applicable):
2. Structure location :

3. Type of structure:

o
o

o
o

Levee/Floodwall"
Breakwater

o

Anchored Bulkhead
Pile supported seawall

Revetment

o

o

Gravity Seawall

Other

"Note : If the coastal structure is a levee/floodwall, comp lete section E of Form 3 (Riverine Structures Form). The remainder of this form
does not need to be completed .
4. Material structure is composed of (check all that apply) :

o
o

Stone
Other

D

o

Earthen fill

o

Concrete

Steel

DSand

-----------------------------------­

5. The structure is (check one) :

o

o

D

New or proposed

D

Replacement structure of the same size and design as what was previously at the site .

Existing

Modification of existing structure

Describe in detail the existing structure and/or modifications being make to the structure and the purpose of the modifications .

If existing , please include date of construction :
6. copies of certified "as-built"plans

Dare

D are not attached .

Attach all design analysis that apply.

If "as-bu ilt" plans are not avail able for submittal, please expla in why and submit a sketch with general structure dimensions including : face
slop, height , length , depth , and toe elevation referenced to the appropriate datum (e.g., NGVD 1929, NAVD 1988, etc.)
7. Has a Federal agency with respons ibility for the design of coastal flood protection structures designed or certified that the structures have
been adequately designed and constructed to provide protection against the 1%-annual-chance event?
If Yes, specify the name of the agency and dates of the project completion and certification .

DYes

D

No

If Yes, then no other sections of this form need to be completed ..

DHS/FEMA Form 086-0-27D, AUG 2010

PREVIOUSLY FF81·89D

MT·2 Form 5

Page 1 of 3

B. DESIGN CRITERIA (CONTINUED)
1, DE::~ign Parameters
parameters representing the 1%-annual-chance event or greater used to design the coastal flood protection structure?

a. Were
DYes

No
(number) range from the mean low water elevation of

b, The number of design water levels that were evaluated

feet. The critical water level is

feel to the 1%-annual-chance stillwater surge elevation of
elevations are referenced to is

-----

feet. The datum that these

eg, NGVD 1929, NAVD 1988, etc,}

Attach an explanation specifying which water levels and associated wave heights and periods were analyzed,

c, Were breaking wave forces used to design the structure?

DYes

No

If No, attach an explanation why they were not used
for design,

2, Settlement
a, What is the expected settlement rate at the site of the structure?
Please attach a settlement analysis,

3, Freeboard
a, Does this structure have 1 foot of freeboard above the height of the 1 %-annual-chance wave-height elevation or maximum wave runup
(whichever is
D Yes
No
b Does the structure have freeboard of at least 2 feet above the 1%-annual-chance stillwater surge elevation?

Yes

4, Toe Protection

Specify the type of toe protection:
If no toe protection is provided, provide analysis of scour potential and attach an elevation of structural stability performed with potential
scour at the toe,
5, Backfill Protection

Will the structure be overtopped during the 1 %-annual-chance event?

No

DYes

If the structure will be overtopped, attach an explanation of what measures are used to prevent the loss of backfill from rundown over the
structure, drainage landward, under or laterally around the ends of the structure, or through seams and drainage openings in the structure,

6, Structural Stability - Minimum Water Level

a. For coastal revetments, was a
analysis of potential failure in the landward direction by rotational gravity slip performed
for maximum loads
with minimum seaward water level, no wave action, saturated soil conditions behind the structure, and
Maximum toe scour?
Yes
No

b, For gravity and pile-supported seawalls. were engineering
adequacy using maximum pressures developed in the sliding
Yes

of landward sliding, landward overturning, and of foundation
overturning calculations performed?

D No

c. For anchored bulkheads, were engineering analysis performed for shear failure, moment failure, and adequacy of tiebacks and
deadmen 10 resist loading under low-water conditions?
Yes

No

7, Structural Stability Critical Water level (Note: All structures must be designed to resist the maximum loads associated with the critical
water level to be credited as providing protection from the 1%-annual-chance event.
a, For coastal revetments, were geotechnical analysis performed
gravity slip or foundation failure due to inadequate bearing strength?

the potential failure in the seaward direction by rotational

No

DHS/FEMA Form 086-0-27D, AUG 2010

PREVIOUSLY FF81·89D

MT·2 Form 5

Page 2 of 3

B. DESIGN CRITERIA (Continued)
b. For revetments, were englneenng analysIs or rOCK, nprap, or armor block's stability under wave action or uplift forces on the rock,
riprap or armor blocks performed?
No
Yes
c. Are the rocks graded?

No

Yes

d. Are soil or geotextile fillers being used in the design?

No

Yes

e. For gravity and pile supported seawalls, were engineering analysis of landward sliding, landward overturning, and foundation
adequacy performed?
DYes
No

o

f. For anchored bulkheads, were engineering analysis of shear and moment failure performed using "shock" pressures?
Yes

No

For all analysis marked "No" above for the appropriate type of structure, please attach an explanation for why the analysis were not
perfonmed.

8. Malerial Adequacy
conditions at the structure site is

life of the structure given the

The

years.

9. Ice and ImQact Alignment
a. Will the structure be subject to ice forces?

Yes

No

If Yes, attach impact analysis and design for details for such forces.

b. Will the structure be subjected to impact forces from boats, ships, or large debris?

Yes

No

If Yes, attach impact analysis.

10. Structure Plan Alignment
The structure is (check one):

o

Part of a continuos structure redundant return walls at frequent intervals.

Isolated

Please provide a map showing the location of the structure and any natural land features that shelter the structure from wave actions,
C. ADVERSE IMPACT EVALUATION
If the structure is new, proposed, or modified, will the structure impact flooding and erosion for areas adjacent to the structure?
No If Yes, attach an explanation

Yes

D. COMMUNITY ANDIOR STATE REVIEW
Has the design, maintenance, and impact ofthe structure been reviewed and approved by the community, and any Federal. State, or local agencies
having jurisdiction over flood centrol and ceastal construction activities in the area the structure impacts?
Yes

o

No

If Yes, attach a list of agencies who have reviewed and approved the project,
If No, attach an explanation why review and approval by the appropriate community or agency has not been obtained,
E. CERTIFICATION
As a Professional Engineer, I certify that the above structures will withstand all hydraulic and wave forces associated with the 1%-annual-chance
flood without significant structural degradation, All documents submitted in support of this
are correct to the best of my knowledge. I
understand that any false statement may be punishable by fine or imprisonment under Title 8 of the United States Code, Section 1001.

I

Certifier's Name

License No,

Company Name

Telephone No.

Signature

I Expiration Date
Fax No,

Date

Seal (optional)

OHSIFEMA Form 086-0·270, AUG 2010

PREVIOUSLY FF 81·890

MT-2 Form 5

Page 3 of 3