2021-08-24 Boat Ramp Grant applicationU.S. Army Corps of Engineers (USACE)
Form Approved -
APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT
OMB No. 0710-0003
33 CFR 325. The proponent agency is CECW-CO-R.
Expires: 02-28-2022
The public reporting burden for this collection of information, OMB Control Number 0710-0003, 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 the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services,
at whs.mc-alex.esd.mbx.dd-dod-information-collectionsLmail.mil. 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 APPLICATION TO THE ABOVE EMAIL.
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 part 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.
System of Record Notice (SORN). The information received is entered into our permit tracking database and a SORN has been completed (SORN #A1 145b)
and may be accessed at the following website: http://dpcid.defense gov/Privacy/SORNsindex/DOD-wide-SORN-Article-View/Article/570115/al l45b-ce.aspx
(ITEMS 1 THRU 4 TO BE FILLED BY THE CORPS)
1. APPLICATION NO. ]`_FIELD
OFFICE CODE
3. DATE RECEIVED
4. DATE APPLICATION COMPLETE
(ITEMS BELOW TO BE FILLED BY APPLICANT)
5. APPLICANT'S NAME
8. AUTHORIZED AGENT'S NAME AND TITLE (agent is not required)
First - Rodney Middle - 4t Last - Storm
First - William Middle -J Last - Glismann
Company - City of Blair
Company - HGM Associates Inc.
E-mail Address-rstorm@blairnebraska.org
E-mail Address-bglismann@hgmonline.com
6. APPLICANT'S ADDRESS:
9. AGENT'S ADDRESS:
Address- 218 S 16th Street
Address- 5022 S 114th St. Suite 200
City - Blair State - NE Zip -68008 Country -USA
City - Omaha State - NE Zip -68137 Country -USA
7. APPLICANT'S PHONE NOs, w/AREA CODE
10. AGENTS PHONE NOs. MAREA CODE
a. Residence b. Business c. Fax
a. Residence b. Business c. Fax
402-426-6693 402-426-4195
402-346-7559
STATEMENT OF AUTHORIZATION
�,m a.
11. 1 hereby authorize, 1 ` r`("it b 5,,,idtp act in my behaff, s my agent in the processing of this application and to furnish, upon request,
supplemental information in support of this permit plication.
" J — " 2021-08-23
SI RE OF APPLICANT DATE
NAME, L , ATION, AND DESCRIPTION OF PROJECT OR ACTIVITY
12. PROJECT NAME OR TITLE (see instructions)
Blair - Missouri River Boat Ramp Docks
13. NAME OF WATERBODY, IF KNOWN (if applicable)
14. PROJECT STREET ADDRESS (if applicable)
Missouri River
Address
15. LOCATION OF PROJECT
Latitude: -N 41 deg 33'06.8" Longitude: -W 96 deg 05'47.9"
City - State- Zip -
16. OTHER LOCATION DESCRIPTIONS, IF KNOWN (see instructions)
State Tax Parcel ID Municipality Blair NE
Section - 8 Township - 18 N Range - 12 E
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17. DIRECTIONS TO THE SITE
Site is at the Missouri River on Fairview Road, 0.45 miles east of the intersection with 4th Sheet. Fairview Road is approximately 300 feet
north of US Hwy 30.
18. Nature of Activity (Description of project, include all features)
The project is the installation of two new docks on the Missouri River for Blair Boat Ramp access to the river. The two new docks will be
attached to steel pipe piling to anchor the docks in place and allow them to float up and down with the change in the river water level. Each
dock will be attached to two piles permanently driven into the ground.
19. Project Purpose (Describe the reason or purpose of the project, see instructions)
Replacement of existing boat ramp docks used for boat mooring and launching that were installed in 1994. These docks did not use piling to
anchor them in place.
USE BLOCKS 20-23 IF DREDGED AND/OR FILL MATERIAL IS TO BE DISCHARGED
20. Reason(s) for Discharge
There will be no dredged or fill material discharged.
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
22. Surface Area in Acres of Wetlands or Other Waters Filled (see instructions)
Acres
or
Linear Feet
23. Description of Avoidance, Minimization, and Compensation (see instructions)
ENG FORM 4345, FEB 2019 Page 2 of 3
24. Is Any Portion of the Work Already Complete? 1-1 Yes ® No IF YES, DESCRIBE THE COMPLETED WORK
25. Addresses of Adjoining Property Owners, Lessees, Etc., Whose Property Adjoins the Waterbody (if more than can be entered here, please attach a supplemental list).
a. Address- Property to South: (Owner address) Union Pacific Railroad 1400 Douglas Street
City - Omaha State - NE Zip - 68179
b. Address- Property to East: (Owner address) State of Iowa 800 Lincoln Way
City - Ames State - IA Zip - 50010
c. Address- Property to North: Box Lake Cattle Co. 1137 S Hwy 30
City - Blair State - NE Zip - 68008
d. Address-
City - State - Zip -
e. Address-
City - State - Zip -
26. List 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
None
* 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 accute. I further certify, th t I possess the authority to undertake the work described herein or am acting as the duly authorized agent of the
applicant. i
SIGNAT -E 0 APPLICANT 'DATE SIGNATURE OF AGENT DATE
The Application m st 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, FEB 2019 Page 3 of 3