5600-PM-BMP0324
Rev. 4/2014
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF MINING PROGRAMS
Module 1: Application for Bituminous Underground Mine,
Coal Preparation Plant and/or Coal Refuse Disposal Area
Before completing this form, read the step-by-step instructions provided with this Permit Application
Package.
SECTION A. PROJECT INFORMATION
Operation Name:
Permit No. (existing site):
SECTION B. APPLICANT INFORMATION
Applicant Name
Applicant Type
Individual
PA Corporation
Mailing Address
Non-PA Corporation
General Partnership
(Street # and Name or P.O. Box)
Limited Partnership
Municipality
Other
(City)
(State)
(Zip Code + Four)
Pending
- VOLUNTARY (Telephone #)
(FAX #)
(Social Security
Number)
(if individual)
(Federal Tax ID #)
Application Contact
(Mining Operators License #)
Type of Mining Activity
Underground Mine
(Last Name)
(First Name)
(MI)
(Social Security #)
Voluntary
Coal Preparation
Refuse Disposal
Other
(Title)
Yes
Mailing Address
Blasting Anticipated
(Street # and Name or P.O. Box)
(City)
(State)
(Zip Code + Four)
(Email)
Application Type
New Permit
Permit Revision
Permit Transfer
Permit Revision Description:
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Renewal
No
5600-PM-BMP0324 Rev. 4/2014
SECTION C. SITE INFORMATION
Location of Operation – for underground mines provide main portal location
County(ies)
Municipality(ies)
County Code
U.S.G.S. Map Name(s)
Map Coordinates (center of proposed permit area) (center of main portal for underground mines)
Latitude
°
'
"
Longitude
°
'
"
Name(s) of receiving stream(s)/Chapter 93 Classification
MSHA Mine I.D. No. (include date of issuance)
Site Contact
(Last Name)
(First Name)
(MI)
(Title)
Mailing Address
(Street # and Name or P.O. Box)
(City)
(State)
(
)
(Email)
Extent of Mining
(Zip Code + Four)
Ext.
(Telephone #)
(FAX #)
Permitted
Proposed under
this application.
Total
Underground Mines:
Underground Permit Area
acres
acres
acres
Subsidence Control Plan Area
acres
acres
acres
acres
acres
acres
acres
acres
acres
acres
acres
acres
Disposal Site
acres
acres
acres
Support Area
acres
acres
acres
Total Refuse Area plus Support Area
acres
acres
acres
Coal Preparation Activity Area
acres
acres
acres
Surface Activity Site Area for Underground Mines (attach list as needed)
Total Surface Activity Site Area for Underground Mines
Coal Refuse:
Comments:
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5600-PM-BMP0324 Rev. 4/2014
SECTION D. PERMIT COORDINATION
If coal processing activities are proposed, will the total amount of coal processed be equal to or greater than 200 tons/day?
Yes
No (If yes, please document the permit number below.)
BAQ-GPA/GP Permit Number:
Will underground tanks for storage of fuel or chemicals be located within the proposed permit area?
Yes
No
(if Yes, please complete Module 10.8)
SECTION E. APPLICATION FEE (make check payable to “Commonwealth of Pennsylvania”)
Item
Fee
Totals
NEW PERMIT APPLICATIONS
Bituminous Coal underground mining permit
Bituminous Coal refuse disposal permit
Bituminous Coal preparation plant permit
$5,750
$3,250
$1,650
PERMIT REVISIONS
Bituminous underground mining permit
Bituminous Coal refuse disposal permit
Bituminous Coal preparation plant permit
$1,250
$1,250
$1,250
Permit Transfer
All
Bond Liability Revision
$250
$100
Permit Renewal
All
$250
NPDES
New
Renewal, Modification, and/or Transfer
$1,000
$500
GENERAL PERMIT – AIR QUALITY
BAQ-GPA/GP 12
$1,000
WATER OBSTRUCTIONS AND ENCROACHMENT (fee is for each, include multiples in total)
For stream or wetland obstructions and encroachments, calculate the appropriate fee
outlined in 25 Pa. Code Chapter 105 Section 105.13 (regarding Fees (revised
February 16, 2013)) using the Chapter 105 Fee(s) Calculation Worksheet
3150-PM-BWEW0553. Submit the calculation worksheet (3150-PM-BWEW0553) and
a description of the activity with this module.
$
SUBMERGED LANDS LICENSE OF COMMONWEALTH (105.35) (Annual Fees*)
For a submerged lands license of the Commonwealth, complete and submit the “Application for Transfer
of Permit1/ and Submerged Lands License Agreement” (3150-PM-BWEW0016)
Water Obstruction & Encroachment and Dams ($750 annual X No. Years)
$
Areas occupied by Facilities ($150 per tenth of an acre X No. Years)
$
Barge fleeting and mooring areas, ($30 per tenth of an acre X No. Years)
$
(*) Annual Fees are reevaluated during Permit Renewal
$
TOTAL
(1)
(2)
$
No fee is required if the dam has a contributing drainage of 100 acres or less, the greatest depth of water at
maximum storage elevation is 15 or less and the maximum impounding capacity is 50-acre feet or less.
Note: Fees are subject to change upon publication in the Pennsylvania Bulletin.
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5600-PM-BMP0324 Rev. 4/2014
SECTION F. CONSULTANT
(if more than one consultant prepared this application provide information on separate sheets)
(Last Name)
(First Name)
(Title)
(MI)
(Name of Consulting Firm)
Mailing Address
(Street # and Name or P.O. Box)
(City)
(State)
(
)
(Email)
(Zip Code + Four)
Ext.
(Telephone #)
(FAX #)
SECTION G. LAND USE INFORMATION
Have you submitted the Act 67, Act 68, and Act 127 Notification Letters to the municipality and county where the mining project is
proposed?
Yes
No
List the municipality(ies) and county(ies) that received the Act 67, Act 68, and Act 127 notification letters:
(Attach a separate "Section G. Land Use Information for each Municipality or County listed.)
Complete for new permits and all major revisions that include new surface area.
1. Is there an adopted county or multi-county comprehensive plan?
2. Is there an adopted municipal or multi-municipal comprehensive plan?
3. Is there an adopted county-wide zoning ordinance, municipal zoning ordinance or joint municipal ordinance?
Yes
Yes
Yes
No
No
No
If "No" is answered to questions 1, 2, or 3, proceed to Section H, Additional Related Information.
4. Does the project meet the provisions of the zoning ordinance or does the proposed project have zoning approval?
Yes
No
(If zoning approval has been received, attach documentation.)
5. Applicants are encouraged to submit copies of local land use approvals or other evidence of compliance with local
comprehensive plans and zoning ordinances. Have you submitted local municipal and county approval letters for this mining
project with this permit application?
Yes
No
(if yes, please attach the local municipal and county approval letters.)
6. Have you addressed any concerns from the local municipal and county prior to submitting the application to the Department?
Yes
No
(If yes, please attach all correspondence addressing the concerns.)
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5600-PM-BMP0324 Rev. 4/2014
SECTION H. ADDITIONAL RELATED INFORMATION
Name and Address of Public Review Office where a copy of this application is on file for public review. (reference Appendix B if
appropriate)
Have you paid all reclamation fees to the Federal Office of Surface Mining Reclamation and Enforcement as required by the
Federal Surface Mining Control and Reclamation Act of 1977 (30 USC 1232)?
Yes
No
Provide the following as applicable to the proposed operation:
Pre-Application No.
Small Operator Assistance Program (SOAP) Project No.
Notice of Intent to Explore No.
PNDI – Search results
Yes
No
(if yes, complete Module 4.7)
Environmental Justice Areas
Yes
No
(if yes, provide plan for enhanced public participation)
Application Date
SECTION I. AFFIDAVIT
Commonwealth of Pennsylvania, County of
I,
being duly sworn, according to law, depose
and say that I (am the applicant) (am an officer or official of the applicant) (have the authority to make this application) and that
the plans, reports and documents submitted as part of the application are true and correct to the best of my knowledge and
belief. I am aware that there are significant penalties for submitting false information, including the possibility of fine and
imprisonment.
Sworn and Subscribed to Before Me This
day of
(month)
(year)
Signature of Applicant or Responsible Official
Signature of Notary Public
Name (Typed) of Applicant or Responsible Official
Notary Seal
Address of Applicant
Address of Applicant
Applicant Title and Corporate Seal
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