Applicant Name:*

Address: *

Phone/Fax: *

E-mail: *

Local Jurisdiction or Lead Agency/Permittee (check one): *

Escalon Lathrop Lodi Manteca Ripon Stockton Tracy San Joaquin County

SJCOG Caltrans SJAFCA SSJID SEWD EBMUD Other:

Local Jurisdiction/Lead Agency Contact: *

Project Title (per referral notice/advisory agency notice): *

Project Description: *

Current Site Use: *

Assessor Parcel #s:*

Total Acres: *

Is an Army Corp. 404 Permit required?*

Yes

No

A. All APPLICANTS, check ONE of the following:

Decline Coverage

Request Coverage

I, we, DECLINE coverage pursuant to the SJMSCP. I, we, understand that declining coverage pursuant to the SJMSCP will require undertaking negotiations with the Local Jurisdiction and Permitting Agencies to avoid potential, significant, adverse impacts to biological resources where such impacts may occur. I, we, verify that the information contained this application is true and correct.

I, we, REQUEST coverage pursuant to the SJMSCP. I, we, understand that this project may be subject to Habitat Technical Advisory Committee review and approval to gain coverage pursuant to the SJMSCP and that signing this form constitutes authorization for SJCOG, Inc. representatives to enter the subject property for the purpose of assessing biological resources and compliance with the SJMSCP. I, we, verify that the information contained in this application is true and correct.*

I certify that all statements on this form are true and complete to the best of my knowledge and belief. I understand that any falsification of the information on this form may, if I am accepted, be considered grounds for immediate dismissal.*

Landowner Name (if different from Applicant)

Date*

All applicants, attach the following information:
(including those opting OUT of the SJMSCP

Location Map(s)

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(DOC, DOCX, XLS, XLSX, TXT)

Map(s) or Site Plan(s)

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Prior Agreement Projects Only, include:

File-Stamped/Dated Copy of Notice of Determination or Completion approving environmental analysis

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Copy of Biological Resources Analysis identifying approved mitigation measures for the project from approved or certified environmental document

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(DOC, DOCX, XLS, XLSX, TXT)