1. PROJECT SPECIFIC INFORMATION
Project Route/Type
INDOT Des. Number	Contract Number:
County
RFC Date	Letting Date:

2. APPLICATION BACKGROUND
Project Manager Designer/Firm
Submittal Date	Submittal Number
ES Reviewer/Contact Info.
Review Date

Review columns are abbreviated as follows: Sufficient (S), Deficient (D), and Not Applicable (NA). All items marked deficient require resolution from the designer prior to INDOT acceptance of the application.

3. STATE FORM 51937
S	D	NA	I: General Application Requirements
A) Uses the most recent State Form 51937 application used (version R5/7-18) Reviewer Notes:

S	D	NA	II: Applicant Information
A) Applicant contact information reflects the appropriate EWPO Team Lead or Manager Reviewer Notes:
B) Agent blocks are complete and accurate Reviewer Notes:

S	D	NA	III: Project Location
A) Blocks in this section are complete and accurate Reviewer Notes:
B) Driving directions include distances (mileage) and address Reviewer Notes:

S	D	NA	IV: Existing Conditions on the Project Site
A) The appropriate boxes for lake, stream, and/or wetland impacts are checked Reviewer Notes:
B) Uses the correct names (USGS 7.5 minute series) provided for any lakes or streams that are located within the project site Reviewer Notes:
C) The total acreage of any wetlands located within the project site matches the waters report (note that this acreage is not necessarily the same as the impact acreage) Reviewer Notes:
D) The date of the wetland delineation is provided Reviewer Notes:

S	D	NA	V: Project Impacts
A) Does the “Activity Description” meet the following requirements: Overall description clarifies the waters resource(s) that will be impacted and is not solely focused on the roadway or structure work Dimensions of riprap are mentioned (length, width, and depth) Existing structure dimensions (length, width, and height) Proposed structure dimensions (length, width, and height) Total cumulative impacts to streams (linear feet) Total cumulative impacts to streams and wetlands (acres) A short description of any temporary impacts associated with the project and a brief statement regarding the restoration of any areas impacted by temporary fill There is an activity description in the application; does not just say “see attached” Reviewer Notes:
B) The “Purpose of Project” explains why the project is necessary (should include explanation of riprap if applicable) Reviewer Notes:
C) Does the “For Lake Impact” box meet the following requirements (check all that apply): Cumulative linear feet of shoreline that will be impacted Type of permanent fill, volume of fill (cumulative), and acres of fill (cumulative) below OHWM (temporary impacts should be quantified in an attached exhibit) Appropriate box checked for presence/absence of vegetation and if there will be natural shoreline stabilization Type of permanent open water fill and acres of fill (cumulative) beyond the shoreline Reviewer Notes:
D) Does the “For Stream Impact” box meet the following requirements: Cumulative linear feet and acre(s) of permanent impacts to streams Type(s) of permanent fill material and volume of this material that will be placed below OHWM Proposed start and end date that are consistent with the project’s letting date Channel width and depth are provided and match those listed in the waters report Cross-sectional area below the OHWM that match the plan sheets The type of structure that will be installed The structure dimensions Stream substrate that matches the waters report The type of permanent fill material for any open water impacts and acre(s) Reviewer Notes:
E) Does the “For Wetland Impact” box meet the following requirements: Type of permanent fill material Cumulative permanent acres of wetland impacted with a breakdown of impacts by wetland type (emergent, scrub-shrub, and forested) Reviewer Notes:

S	D	NA	VI: Application Attachments
A) Do the project plans meet the following requirements: Plans represent both the existing and proposed project conditions (this can be addressed on the same plan page so long as each can be clearly reviewed) All jurisdictional streams and wetlands are labeled on the plans with the appropriate USGS 7.5 minute series name Cross sections are provided for all wetland impacts with a label showing the boundary of the wetland Cross sections are provided for stream impacts with labels for the OHWM and flow-line elevation Plans do not contain excessive detail that prevents review of impacts Flow direction of any stream is noted on the plans Dimensions of riprap (length, width, and depth) placed below the OHWM is noted in the plans The impacts (linear feet and acres) reflect the amount in the application form For culverts, there is a structure long profile that shows the riprap flush with stream elevations Reviewer Notes:
B) Does the waters report/wetland delineation meet the following requirements: Most recent version of the report and has a PreJD form signed by the preparer of the report or a representative of INDOT-ES The waters report and/or wetland delineation is less than five years old Accounting of all streams, wetlands, and/or other waters located within the project limits (including confirmation of any avoided waters) Correct wetland boundary or boundaries used to calculate impacts Correct ordinary high water mark/s (OHWMs) noted in plans and used to calculate impacts Correct wetland types (emergent, scrub-shrub, forested) referenced in the application Includes a location map where the location is displayed sufficiently for regulatory agencies to locate project Includes photos of the project area Reviewer Notes:
C) Other Attachments: Section 106 and Section 7 (IDNR & USFWS) correspondence is included in the application The Section 7 correspondence is less than five years old (Note: new coordination will be needed for all correspondence greater that five years old) The Section 7 correspondence states that no species were noted in the vicinity of the project or will not likely to impact any ETR species INDOT Hydraulics memo is included and includes the proposed structure For USACE Detroit District, include the Request for Corps JD Form Reviewer Notes:
D) If a project has impacts for multiple jurisdictional waters, a summary table should be provided. Did this table meet the following requirements: Itemization of the impacts to each individual stream (length and acres below OHWM) Itemization of impacts to each individual wetland (acres) Volume of fill below OHWM (cubic yards) to each stream Volume of fill that will be placed in each wetland Existing structure dimensions (length, width, and height) Proposed structure dimensions (length, width, and height)
F) Does temporary impact information meet the following requirements (these should not be listed within permanent impacts in State Form 51937): Type of temporary fill material (should be non-erosive) Volume (cubic yards) and area (acres) associated with temporary measures below OHWM Temporary acres of impact to any wetland(s) Plan or drawing showing the approximate location and dimensions of the proposed temporary measure(s) Expected amount of time the temporary measures will be in place Number and dimensions (diameter and length) of pipes required for a temporary stream crossing (if applicable) Restoration plan including an appropriate seed mix Note that temporary measures should be designed to handle a two-year storm event. Reviewer Notes:

Comments:

5. DOCUMENTATION
Have all databases been updated (Reference SOP for database updates after application submittal): Submittal 1 Submittal 2 Submittal 3 Submittal 4 Submittal 5 Submittal 6 Submittal 7 Final Submittal Receive Permit Email Milestones EWPS PSCS ProjectWise Commits.