Environmental Protection Commission of Hillsborough County
Roger P. Stewart Center
3629 Queen Palm Drive · Tampa, FL 33619
Ph: (813) 627-2600 · Fax: (813) 627-2630

www.epchc.org

Application for a

Delegated Tampa Port Authority Minor Work Permit - MWP09

Pursuant to Chapter 95-488, Laws of Florida, and Interlocal Agreement between the EPC and the Tampa Port Autthority, and person desiring to dredge, fill, build or moor any structure on submerged lands with the Port District must apply to the EPC, if the site falls within the delegated areas. For full guidelines, see the EPC Minor Work Permit Guidelines.

Any required fee must be submitted with this application. Incomplete applications, including the fee, will not be processed until all missing information is provided.

Please direct any questions you may have regarding Minor Work permitting to EPC Wetlands Department directly at (813) 627-2600.

* Indicates a required field.

CHECK ONE:

NEW

$650 Review Fee

PERMIT REVISION

$100 Review Fee, construction has not begun

$360 Review Fee, construction has begun

AFTER-THE-FACT

$650 Review Fee

WN#

Email Address to send Invoice to: *

SECTION I

1. Brief Minor Work Project Description

2. Property Owner Information

Request to be present at site inspection.

Owner First Name *

Owner Last Name *

Company Name & Title (if applicable)

Mailing Address *

City *

State *

Zip Code *

Owner Telephone Number(s) *

Fax

Email Address *

3. Authorized Agent Information (if applicable)

Are you using an agent?

Yes

Request to be present at site inspection.

Agent First Name *

Agent Last Name *

Company Name (if applicable)

Street Address *

City *

State *

Zip Code *

Telephone Number(s)

Fax

Email Address *

SECTION II

1. Location of Proposed Project

Site Street Address *

City *

State *

Zip Code *

Folio Numbers(s) of Site *

Parcel ID: *

	Required
Section	Required
Township	Required
Range	Required

Name of Water Body / Waterway at Proposed Project *

2. Proposed Use

Proposed: *

Private Single-Dwelling

Private Multi-Family Dwelling (Condominium, Apartment, etc.)

Commercial

Other

Explain, if Other

3. Owner of Submerged Lands

Owner *

Leased Port Property or Port Easement (check box if applicable)

4. Previous Tampa Port Authority Permits Issued at This Location

1st Permit Number

1st Date +

2nd Permit Number

2nd Date +

5. Project Description

Check to confirm that your project is not located in critical habitat for smalltooth sawfish or gulf sturgeon, as applicable. *

Confirmed

Check to confirm that if your project is located in waters accessible to manatees, the project shall not affect or will not directly or indirectly likely adversely affect manatees, as applicable. *

Confirmed

A. Structures

New Work

Maintenance / Replacement

Addition / Modification

1) Dock, Observation Deck, Pier, or Elevated Boardwalk (check applicable boxes)

Dock

Observation Deck

Pier

Elevated Boardwalk

	(if applicable)
Length of Shoreline (in linear feet)	(if applicable)
Number of Proposed Docks	(if applicable)
Number of Boat Slips / Lifts	(if applicable)
Length from OHW/MHW to Waterward Edge of Structure (in feet)	(if applicable)
Width of Structure (in feet)	(if applicable)
Mooring Water Depth at O/MLW (in feet)	(if applicable)
Existing Structure Area (in square feet)	(if applicable)
Proposed Structure Area (in square feet)	(if applicable)
Overall Area of Facility (in square feet)	(if applicable)

2) Seawalls, Rip-Rap, Revetments, or Other Shoreline Stabilization (check applicable boxes)

Seawall

Rip-Rap

Revetment

Other Shoreline Stabilization

	(if applicable)
Length of Shoreline at Site (in linear feet)	(if applicable)
Length of Work Proposed Along Shoreline (in linear feet)	(if applicable)
Seawall Vertical Height (in feet)	(if applicable)
Rip-Rap Slope - Horizontal Distance (in feet)	(if applicable)
Rip-Rap Slope - Vertical Height (in feet)	(if applicable)
Type of Material	(if applicable)
Dredged Volume (in cubic feet)	(if applicable)
Filled Volume (in cubic feet)	(if applicable)

3) Other Type of Structure

Other

B. Dredging / Excavation

New Work

Maintenance

Refer to the Checklist for Dredge Projects for applicable information.

1) Dimensions of Areas to be Dredged / Excavated

	(required)
Length (in feet)	(required)
Width (in feet)	(required)
Total Area (in square feet)	(required)
Depth - Existing	(required)
Depth - Proposed	(required)
Volume - Above OHW/MHW	(required)
Volume - Below OHW/MHW	(required)
Volume - Total	(required)
Area - Above OHW/MHW	(required)
Area - Below OHW/MHW	(required)
Area - Total	(required)

2) Type of Material

3) Storage of Material

On-site Storage

Off-site Disposal Site

If material is to be taken off-site, upload the Affidavit of Authorization from the disposal site's property owner (as applicable to this project) with the site's location, the method of material storage, and the haul routes described: 🛈

Please Check

I have filled out and attached all required information listed on the Dredge Project Checklist applicable to this project.

C. Filling

Check if Filling

Refer to the Checklist for Fill Projects for material sampling requirements and other applicable information.

1) Volume

	(required)
Volume - Above OHW/MHW	(required)
Volume - Below OHW/MHW	(required)
Volume - Total (in cubic yards)	(required)

2) Area

	(required)
Area - Above OHW/MHW	(required)
Area - Below OHW/MHW	(required)
Area - Total (in square feet)	(required)

3) Containment

Seawall

Dikes

Other

If Other:

4) Type of Material

5) Source of Material

On-site

Off-site

If Off-site:

6. Work Schedule

To Begin On: * +

To Be Completed By: * +

7. Remarks / Comments for Project

Enter any additional remarks for the project.

8. Public Interest Statement

Accordingly, in the Comment Box provided below, describe how your proposed project is not contrary to the public interest based on the criteria outlined in Section II. D.1. of the Tampa Port Authority Submerged Lands Management Rules.

a. The decision to authorize the use of Jurisdictional Lands requires a determination that such use is not contrary to the public interest, except for lands within Aquatic Resource Protection Areas, in which case it must be determined that the use is in the public interest. In all cases it will be in the responsibility of the applicant to provide evidence as to the public interest impact of the proposed activity or use.

b. The public interest determination requires an evaluation of the probable impacts of the proposed activity on Jurisdictional Lands and the associate water body. All direct and indirect impacts related to the proposed activity as well as the cumulative effects of those impacts shall be taken into consideration. Relevant factors to be considered include: conservation, general environmental and natural resource concerns, wetlands values, cultural values, fish and wildlife values, flood hazards, floodplain values, land use, navigation, shore erosion and accretion, recreation, water supply and conservation, water quality, aesthetics, economics, public health and safety, relative extent of the public need for the proposed use or activity, reasonable alternative locations and methods to accomplish the objective of the proposed use or activity, potential detrimental effects on the public uses to which the area is otherwise suited, the effect on cultural, scenic and recreational values, and the needs and welfare of the people.

Public Interest Comment Box: *

SECTION III

1. Adjacent Property Owners

Project site adjacent riparian property owners:

1st Adjacent Property Owner Name(s) *

Company Name & Title (if applicable)

Mailing Address *

City *

State *

Zip Code *

2nd Adjacent Owner *

Company (if applicable)

Mailing Address *

City *

State *

Zip Code *

SECTION IV

TERMS OF AGREEMENT

OWNER / APPLICANT ACKNOWLEDGEMENT *

I am the property owner and applicant.

I am an agent filling out the application on behalf of the owner.

InstructionsOwner/Applicant must complete this authorization form. For multiple properties, please provide a separate form for each property. For business organizations (e.g. LLC, corporations, partnerships), this form must be signed by a person authorized to bind the organization. A business organization or person who has sufficient real property interest is required to authorize access to the property.

A. OWNER/APPLICANT ACKNOWLEDGEMENT

By signing below, I or the business organization, am applying for a permit(s)¹ to conduct the activity(ies) described in the application. I am familiar with the information contained in the application and represent that it is true, complete and accurate. I understand this is an application and not a permit, and that work prior to approval may be a violation. I understand that this application and any permit issued thereto, does not relieve me of any obligation for obtaining any other required federal, state, water management district or local permit prior to commencement of activities. I agree to operate and maintain the proposed activity in compliance with permits and laws, unless the EPC authorizes transfer of the permit to a different responsible entity. I understand that my application will not be processed if there is any missing, insufficient, or invalid information or insufficient fees. I understand I may have to provide any additional information/data that may be necessary to provide reasonable assurance of evidence to show that the proposed project will comply with applicable environmental standards/laws. I agree that upon written concurrence, the EPC may make changes to the application based on revised drawings and/or additional information provided by agent or applicant. I further agree EPC can unilaterally change non-substantive typographical errors. I understand that knowingly making any false statement or representation in this application is a violation of EPC Act and rules and may result in, among other things, revocation of the permit or denial of the application.

B. CERTIFICATION OF SUFFICIENT REAL PROPERTY INTEREST AND AUTHORIZATION FOR STAFF TO ACCESS THE PROPERTY *

By signing below, I certify that I, or the business organization, possess sufficient real property interest in or control over the land upon which the activities described in this application are proposed and that I have legal authority to grant permission to access those lands. I hereby grant permission, evidenced by my signature below, for staff of the EPC to access, inspect, and sample the lands and waters of the property as necessary for the review of the proposed works and other activities specified in this application. I authorize EPC, its agents, and assigns to enter the property as many times as may be necessary to make such review, inspection, and/ or sampling. Further, I agree to provide entry to the project site for such agents or personnel to monitor and inspect permitted work if a permit is granted.

C. DESIGNATION OF AUTHORIZED REPRESENTATIVE (IF APPLICABLE) *

By signing below, I authorize the representative listed below to act on my behalf, or on behalf of the organization, to process the application; to negotiate revisions; to accept or agree to conditions or stipulations; and to furnish, upon request, supplemental information in support of the application. In addition, I authorize the representative listed below to bind me, or the organization, to perform any requirements that may be necessary to procure the permit or authorization.

¹ The term “permit” is used generally herein to mean a permit, an authorization, a wetland delineation, etc. For a wetland delineation request, it is understood that this is not an application to impact wetlands or conduct activities in wetlands other surface waters

Authorized Representative Name *

Authorized Representative's Telephone *

Owner/Applicant Signature *

clear

Printed Name of Signature: *

Date (MM-DD-YYYY) * +

Business Organization (if applicable)

Title

Please download, complete and sign the Owner's Authorization Form. Then upload the signed authorization document here: *

SECTION V

Project Drawings uploads: ( Site Plan, Plan Review, Profile) *