Petition for a Formal Wetland and

Surface Water Determination

Telephone (561)686-8800
Florida WATS 1-800-432-2045
FAX (561)682-6896
Please read all of the instructions, and type or print the requested information. To ensure efficient processing of your petition, please submit this original signed form and one copy, with the appropriate fee. Page 2 of 4 contains a list of required supporting information.
OWNER / PETITIONER/ENTITY TO RECEIVE
FORMAL WETLAND DETERMINATION
Name / Name
Address / Address
City, State, Zip / City, State, Zip
Telephone / Telephone
Email / Email
PROJECT INFORMATION
Name (Including The Phases Covered By This Petition)
City, Town, or Village (If Applicable)
Total Project Acreage, Including All Phases / Phase Areas (If Applicable)
Section(s) or Government Lot(s) / Township / S / Range / E
Section(s) or Government Lot(s) / Township / S / Range / E
Section(s) or Government Lot(s) / Township / S / Range / E
Amount of Fee Submitted
If the proposed project boundaries include any areas for which District or Department of Environmental Protection or Corps of Engineers permits, applications, declaratory statements or Consent Orders have been received, please list names, file numbers and types of activity; and provide a copy of all pertinent documents.
DEP
WMD
COE
FOR DISTRICT USE ONLY
APPLICATION NUMBER
DATE RECEIVED
FEE RECEIVED
ACREAGE

Incorporated by reference in paragraph 40E-4.091(1)(a), F.A.C.

Form 0972(05/2012) Page 1 of 4

Please submit the following supporting information:
one copy of a proof of ownership;
one original and one copy of the United States GS Topo Quad(s) with the property boundaries depicted;
one original aerial photographwith the following depicted: property boundaries, north arrow, date, scale, and direction of flow of any surface waters;
one copy of the USDA Soil Survey sheet(s) with the property boundaries depicted;
and one of the following two sets of items:
one copy of the certified survey information listed in Basis of Review for Environmental Resource Permit Applications within the South Florida Water Management District, 4.5.2(a);
OR
one copy of the approximate delineation information listed in Basis of Review for Environmental Resource Permit Applications within the South Florida Water Management District, 4.5.2(b).
Have any United States Army Corps of Engineers (USACOE), United States DA (USDA), Department of Environmental Protection(DEP), District, or county environmental staff visited the site? If "yes", for each such visit, briefly list in the space below the agency, person(s), date(s) and purpose(s).
Briefly describe the past and present land use activities within the project boundaries for which this determination is sought.

Incorporated by reference in paragraph 40E-4.091(1)(a), F.A.C.

Form 0972(05/2012) Page 1 of 4

THE PETITIONER MUST COMPLETE THE FOLLOWING
I agree to provide any additional information and data that may be necessary to complete this petition.I am familiar with the information contained in this petition, and to the best of my knowledge and belief, such information is true, complete and accurate. I further certify that I possess the authority to petition for a formal wetland and surface water determination in accordance with Section 373.421, Florida Statutes (F.S.), or am acting as the duly authorized agent of a person with such authority. I understand that knowingly making any false statement or representation in this petition is a violation of Section 373.430, F.S.
Typed/Printed Name of Petitioner/Agent / Signature of Petitioner or Agent
(Corporate Title if applicable) / Date
AN AGENT MAY SIGN ABOVE IF THE PETITIONER COMPLETES THE FOLLOWING
I hereby designate and authorize the agent listed above to act on my behalf as my agent in the processing of this petition for a formal wetland and surface water determination and to furnish on request supplemental information in support of the petition. I am familiar with the information contained in this petition, and to the best of my knowledge and belief, such information is true, complete and accurate. I further certify that I possess the authority to petition for a formal wetland and surface water determination in accordance with Section 373.421, F.S. I understand that knowingly making any false statement or representation in this petition is a violation of Section 373.430, F.S.
Typed/Printed Name of Petitioner / Signature of Petitioner
(Corporate Title if applicable) / Date

Incorporated by reference in paragraph 40E-4.091(1)(a), F.A.C.

Form 0972(05/2012) Page 1 of 4

THE PERSON AUTHORIZING ACCESS TO THE PROPERTY
MUST COMPLETE THE FOLLOWING
I either own the property described in this petition or have legal authority to allow access to the property, and I consent to a formal determination being made on the property as described in Section 40E-4.042, Florida Administrative Code. I authorize representatives or personnel from the South Florida Water Management District, after I have received prior notification, to enter the property as many times as may be necessary to make the wetland and surface water determination; and I will provide access throughout the property sufficient to perform the determination. I will attach to this petition documentation demonstrating that I am the owner of the property or that I have legal authority to allow access to the property.
Typed/Printed Name / Signature
(Corporate Title if applicable) / Date
THE PERSON RESPONSIBLE FOR DELINEATING THE WETLAND AND SURFACE WATER BOUNDARIES MUST COMPLETE THE FOLLOWING UNLESS THE PROPERTY IS LESS THAN 10 ACRES IN SIZE.
I hereby certify that I, or someone under my direct supervision, have initially delineated the boundaries of wetlands and other surface waters for the above referenced project by either flagging the boundaries for a certified survey or GPS, or estimating the extent of wetlands and other surface waters on aerial photographs, prior to the District's inspection of the site.
Typed/Printed Name / Signature
(Corporate Title if applicable) / Date

Incorporated by reference in paragraph 40E-4.091(1)(a), F.A.C.

Form 0972(05/2012) Page 1 of 4