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WETLANDS IMPACT EVALUATION

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Submittal Date: Sequence No.: District: Requesting Agency:

1. Does the project have wetland impacts? Type:

2. Identify each wetland site being affected and acreage from each expected to be converted to other use(s).

Wetland Impacts and Mitigation Required

Site No.

Type

T&E

Nature Preserve

Natural Area

Essential Habitat

Size(acres)

Acres of Impact



3. Briefly describe the measures considered to avoid and minimize adverse impacts to the wetlands:


4. Summarize briefly why there are no practicable alternatives to the use of the wetland(s):


5. Mitigation site:

6. Mitigation basin:


7. Local Contact Person: Telephone #: ( ) - ext.
Title: E-Mail:
Company:

8. Additional Information:Memo By: Submitted By: