Joint Application Form, TVA Form 17423 (draft)

TVA RESTRICTED INFORMATION

JOINT APPLICATION FORM Department of the Army/TVA

OMB No. 3316-0060 Exp. Date MM/DD/YYYY

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

Please TAB to gray areas

Name and Mailing Address of Applicant:

Name, Mailing Address, and Title of Authorized Agent:

     

     

Email Address:

     

Email Address:

     

Telephone Number:

Home

     

Telephone Number:

Home

     

Office

     

Office

     

Mobile

     

Mobile

     

Facility/Activity Location (include all known information):

Reservoir

     

Address:

     

Subdivision, Lot No., and/or Tax Parcel No.:

     

Stream Name and Mile:

     

Longitude/Latitude:

     

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 understand that TVA and the U.S. Army Corps of Engineers may contact an Authorized Agent listed above and such Agent may act on my behalf on all aspects of this application. I agree that, if this application is approved by TVA, I will comply with the terms and conditions and any special conditions that may be imposed by TVA. Please note the U.S. Army Corps of Engineers may impose additional conditions or restrictions.

     

     

Date

Name of Applicant (Printed)

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:

     

List of previous DA/TVA permits/approvals

DA

     

TVA

     

Permit Number

Permit Number

Previous Property Owner (if known)

     

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, on paper suitable for reproduction no larger than 11 x 17 inches or in electronic format (dxf, docx, or pdf), must accompany the application. Submit the application 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 Offices

U.S. Army Corps of Engineers Eastern Regulatory Field Office 501 Adesa Parkway., Suite 250 Lenoir City, Tennessee 37771 (865) 986-7296 U.S. Army Corps of Engineers Regulatory Branch 3701 Bell Road Nashville, Tennessee 37214 (615) 369-7500 U.S. Army Corps of Engineers Norfolk District P.O. Box 338 Abingdon, Virginia 24212 (276) 623-5259

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 Western Regulatory Field Office 2424 Danville Road, SW, Suite N Decatur, Alabama 35603 (256) 350-5620 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 Chattanooga Regional Office 4601 N. Access Road, Bldg. B Chattanooga, Tennessee 37415-3825 1-800-882-5263 Tennessee Valley Authority Gray Regional Office 106 Tri-Cities Business Park Drive Gray, Tennessee 37615 1-800-882-5263 Tennessee Valley Authority Guntersville Regional Office 3941 Brashers Chapel Road Guntersville, Alabama 35976 1-800-882-5263 Tennessee Valley Authority Lenoir City Regional Office 260 Interchange Park Drive, LCB 1A-LCT Lenoir City, Tennessee 37772-5664 1-800-882-5263

Tennessee Valley Authority Murphy Regional Office 4800 US Highway 64 West, Suite 102 Murphy, North Carolina 28906 1-800-882-5263 Tennessee Valley Authority Muscle Shoals Regional Office Post Office Box 1010, MPB 1H Muscle Shoals, Alabama 35662-1010 1-800-882-5263 Tennessee Valley Authority Paris Regional Office 2835-A East Wood Street Paris, Tennessee 38242-5948 1-800-882-5263

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 2 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 [??-??-2016] Page 4 of 4

TVA RESTRICTED INFORMATION