Name:

Email:

Phone:

Customer Type:
Land Developer/ConsultantPrivate LandownerAgriculturalOther

Florida County where impact occurs:

—Please choose an option—AlachuaBakerBayBradfordBrevardBrowardCalhounCharlotteCitrusClayCollierColumbiaDeSotoDixieDuvalEscambiaFlaglerFranklinGadsdenGilchristGladesGulfHamiltonHardeeHendryHernandoHighlandsHillsboroughHolmesIndian RiverJacksonJeffersonLafayetteLakeLeeLeonLevyLibertyMadisonManateeMarionMartinMiami-DadeMonroeNassauOkaloosaOkeechobeeOrangeOsceolaPalm BeachPascoPinellasPolkPutnamSanta RosaSarasotaSeminoleSt. JohnsSt. LucieSumterSuwanneeTaylorUnionVolusiaWakullaWaltonWashington

Section/Township/Range where impact occurs (if known):

8 Digit HUC (if known):
—Please choose an option—03070204030702050308010103080102030801030308020103080202030802030309010103090102030901030309020103090202030902030309020403090205030902060310010103100102031001030310020103100202031002030310020403100205031002060310020703100208031101010311010203110103031102010311020203110203031102050311020603120001031200030313000303130004031300080313001103130012031300130314010103140102031401030314010403140105031401060314010703140202031402030314020403140205Not Sure/Other

Size of Impact:

Square FeetAcres

# of Credits Required by Regulatory after ratio adjustment:

Wetland Type Impacted (if known):
—Please choose an option—1 - Seasonally Flooded Basin or Floodplains2 - Wet Meadow3 - Shallow Marsh4 - Deep Marsh5 - Shallow Open Water6 - Shrub Swamp7 - Wooded Swamp8 - BogsU - Upland BufferEstuarineNon-RiparianPalustrine EmergentPalustrine ForestedRiparianRiparian, Non-RiverineRiverineStreamTidal FringeMultiple Types/Other (Indicate in Remarks Section)

Agencies you have contacted (check all that apply):
US Army Corps of EngLocal GovernmentNRCSNoneOther

Any Additional Information Including Location Information and a Short Description of the Project: