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Applicant Info

First Name*
Last Name*
Address1*
City*
State*
Zip*
Phone*
Email*
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Project Details

Local Jurisdiction or Lead Agency/Permittee *
(check one)
1. Escalon
2. Lathrop
3. Lodi
4. Manteca
5. Ripon
6. Stockton
7. Tracy
1. San Joaquin County
2. Caltrans
3. SJAFCA
4. SSJID
5. SEWD
6. EBMUD
7. Other
Local Jurisdiction/Lead Agency Contact*
Project Title*
per referral/advisory agency notice
Project Description*
Current Site Use*
Project Location*
Assessor Parcel Number(s)
Total Acres
Army Corp. 404 Permit required?*
1. Yes
2. No
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Step Three

All Applicants, check one of the following:
Decline 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 in this application is true and correct.
1. Decline
Request Coverage*
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 purposes of assessing biological resources and compliance with the SJMSCP. I, we, verify that the information contained in this application is true and correct.
1. Request
Certification*
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.
Date *
Date
All Applicants, attach the following information:
(including those opting OUT of the SJMSCP)
Location Map(s)
Map(s) or Site Plan(s)
Prior Agreement Projects Only, include:
Copy of Biological Resources Analysis identifying approved mitigation measures for the project from approved or certified environmental document
File-Stamped/Dated Copy of Notice of Determination or Completion approving environmental analysis

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1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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San Joaquin County Multi-Species Habitat Conservation & Open Space Plan - SJMSCP Review Form

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