Delegated DNR Design Concurrence Certification Template

(Revised 1/20/22)

Purpose Statement: The purpose of this certification template is to document Wisconsin Department of Transportation (WisDOT) projects that meet the below eligibility and qualifying criteria demonstrating a lack of waterway/wetland impacts and overall minimal impact to other environmental resources satisfying requirements for the delegated Wisconsin Department of Natural Resources (DNR) design concurrence process described under the Cooperative Agreement. Projects that satisfy said requirements do not require design review and concurrence with DNR, but will require standard construction coordination.

Roles: This template shall be completed by the WisDOT project manager, who will then provide the completed template to the WisDOT Region Environmental Coordinator (REC) for final certification. When the WisDOT project manager is a consultant, the WisDOT supervisor overseeing the consultant must sign the template. Executed templates and supporting information shall be maintained by WisDOT as a record and provided to DNR upon request to demonstrate project certification.

Project Information:

WisDOT Design and Construction IDs	Federal Project IDs (if available)	Legal Description (Township, Range, Section)	County
Project Name	Name of Route of Facility to be improved
Template Preparer Name (WisDOT Project Manager)	Template Preparer Phone#	Template Preparer Email Address
Briefly Describe Proposed Scope of Work

Eligible Projects: Only those project-types designated as Perpetuation projects in PMM 05-10-05 (link below) are eligible for consideration of delegated DNR design concurrence. Projects with an Improvement Concept Code of MISC and all Traffic Improvement Concepts as identified in PMM 05-10-05 are also eligible for template screening consideration.
https://iisgtwyp.wi.gov/ffm/pmm/05/05-10-05e.pdf (must be on the DOT network or VPN)

Qualifying Criteria: Please answer the following project-based questions and note that any selection of “No” disqualifies the project for consideration of delegated DNR design concurrence.

All project work is contained completely within the existing roadway shoulder to shoulder, curb to curb, or back of sidewalk to back of sidewalk, and all ground disturbance occurs in areas of manicured landscaping or regularly mowed grass.
Yes – Meets criterion	No – Project is disqualified

The project does not include ground disturbance or grading in a ditch or stormwater swale, including a center median ditch or swale.

Yes – Meets criterion	No – Project is disqualified

The project does not contain any work on a bridge structure, except for bridges over an existing roadway, railway, utility corridor or trail not containing any water.
Yes – Meets criterion	No – Project is disqualified

If the project area contains culverts, no work will take place on the culvert structure. Additionally, the project work shall be contained within the surface asphalt/pavement and will not disturb any gravel or basecourse material under the road surface within 20 feet of the culvert structure.
Yes – Meets criterion	No – Project is disqualified

The overall project, including all select sites comprises a total area of less than 1 acre of ground disturbance and will not require a Transportation Construction General Permit from DNR.

Note: Ground disturbance for road and parking lot reconstruction is considered only when the pavement and base stone is removed to expose the subsoil, if the basecourse is not removed then it is not considered ground disturbance.
Yes – Meets criterion	No – Project is disqualified

All portions of the project are located outside Tribal lands held in fee, trust, allotted, or reservation status.
Yes – Meets criterion	No – Project is disqualified

The overall project will not temporarily or permanently acquire land or an interest in land or impact access to public lands, such as parks, recreational trails, wildlife refuges and/or state natural areas including public hunting grounds.
Yes – Meets criterion	No – Project is disqualified

A completed project screening utilizing the DNR NHI Public Portal returns an outcome of “No Further Action Necessary” OR “Project Meets No/Low ITA” indicating the project meets Table 1, section 1-A1,1-A2, 1-C1, 1-C2, 1-C3, 1-C4, 1-C5, 1-C6, 1-C7 or 1-C8 qualifying it for a Broad Incidental Take Authorization. Table:https://dnr.wisconsin.gov/sites/default/files/topic/ERReview/bitpermit.pdf#page=6
NHI Public Portal:https://dnrx.wisconsin.gov/nhiportal/public/start
Yes – Meets criterion	No – Project is disqualified

Other Project Requirements: Use of this checklist does not exempt the project from following all applicable local, state and federal laws and regulations including asbestos, migratory bird treaty act, hazardous materials investigations and remediation protocols.

DOT’s Project Managers shall consult with DOT Region Environmental Coordinators during completion of this criteria template.

Certification Statement: Upon executing signature below the identified parties represent all information to be true and accurate, reflecting the most updated project scope. Projects satisfying all eligibility and qualifying criteria hereby meet the intent of delegated DNR design concurrence and no further DNR design concurrence is required. Projects will still require standard construction coordination.

Disclaimer: Any change in project scope requires this certification form to be resubmitted and certified to reflect the most updated set of project details.

Template Preparer Signature: ______________________________________
WisDOT Project Manager or WisDOT Consultant Project Manager Supervisor

Print Name	Date

REC Certification Signature: ________________________________________
Region Environmental Coordinator

Print Name	Date

Note: Be sure to document that this template was used when you are entering environmental document information into the BTS Environmental Document Tracking SharePoint site.