OREGON DEPARTMENT OF STATE LANDS REMOVAL-FILL EMERGENCY AUTHORIZATION APPLICATION
Received Date

DSL File No:
SECTION 1: APPLICANT INFORMATION
Name:	Organization (if applicable):
Mailing Address:	City:	State:	Zip:
Telephone Number:	Email Address:

LANDOWNER INFORMATION (if different than Applicant)
Name:	Organization (if applicable):
Mailing Address:	City:	State:	Zip:
Telephone Number:	Email Address:

SECTION 2: PROJECT LOCATION INFORMATION
Project Address (if different than Applicant):	Nearest City:
County:	Latitude:	Longitude:	Find coordinates: https://www.latlong.net/
Waterway or Wetland:	Name of Waterway:	River Mile (if applicable):
Township	Range	Section	Quarter / Quarter	Tax Lot (s)
Is this a designated State Scenic Waterway?	Yes No
Is this a designated Essential Salmon Habitat (ESH)?	Yes No
Driving Directions:

SECTION 3: DESCRIBE NEED FOR THE PROJECT AND POTENTIAL CONSEQUENCES OF NO ACTION
Is the project required for erosion-flood repair or stream bank stabilization? Yes No Please describe the need for the project and the potential consequences of no action. Declare if the emergency is related to Public Health, Public Safety, and/or Substantial Property including crop, farmland, dwelling, or transportation structure.

SECTION 4: PROPOSED PROJECT INFORMATION
Estimated Impact Details
Name of Waterway or Wetland	Impact (Removal or Fill)	Length (ft)	Width (ft)	Depth (ft)	Volume of Material (cy)	Type of Material	Acres of Impact (wetland)	Duration (Permanent or Temporary)
Total Volume of Removal and Fill (cy):	Total Acres of Impact (Wetland):	Material Disposal Location:
Detailed Description of Project: Please include the following details: Proposed activity, equipment, and construction methods How the work minimizes impacts to wetlands/ waterways How the work is the minimum amount necessary to alleviate the emergency If temporary, how long until removal and/or fill is removed
Date and Time Event Took Place:	Project Start Date:	Project End Date:

SECTION 5: OTHER AGENCIES NOTIFIED
Permitting Agency:	Person Contacted:	Phone:	Email:	Comments:
OR Dept. Fish & Wildlife
Oregon Parks & Recreation
Corps of Engineers

SECTION 6: SIGNATURE

By signing below, I understand:

The information provided herein is, to the best of my knowledge and belief, true, complete, and accurate.

Name:	Applicant Signature	Date

Instructions: The following materials are required to process this request. Submit all materials online, by mail to the regional address below, fax or email (support.services@dsl.oregon.gov).

Attach: ☐ Completed, signed form	☐ Photos

☐ Drawings of proposed work plan including: a) Construction access routes b) Staging areas

Submit online: https://www.oregon.gov/dsl/wetlands-waters/Documents/uploadinstructions_removalfill.pdf
Mail or fax your application to the following address/fax number:

West of the Cascades: Department of State Lands 775 Summer Street NE Suite 100 Salem, OR 97301 Ph: 503-986-5200 Fax: 503-378-4844	or	East of the Cascades: Department of State Lands 951 SW Simpson Avenue, Suite 104 Bend, OR 97702 Ph: 541-388-6112 Fax: 541-388-6480