APPENDIX I
(See Paragraph-6)
FORM 1
Note : If space provided against any parameter is inadequate, Kindly upload supporting document under 'Additional Attachments if any'  at the last part of the Form1. Please note that all such Annexures must be part of single pdf document.
(I) Basic Information
S.No.Item Details
Is your project Comes under Notified Industrial Area NA
Whether proposal involved violation of EIA notificationN/A
Weather Consent to Establishment ObtainedN/A
Upload copy of CTE N/A
1.
Name of the Project/s Proposed New National highway 753 BB Inter corridor route of Bharatmala project Route 3 from Songir village, Dhule Taluka - Dhule District to Visarwadi village, NavapurTaluka – Nandurbar District approximately 114.50 km
Brief summary of projectAnnexure-Brief summary of project
Proposal Number IA/MH/MIS/73795/2018
Project Cost 93611 lacs
2.
S. No. in the schedule7(f) Highways
Project Sector INFRA-2
3. Proposed capacity/area/length/tonnage to be handled/command area/lease area/number or wells to be drilled 114.50 ha.
4.
New/Expansion/ModernizationNew
5. Existing Capacity/Area etc. 114.50 ha.
6. Category of project i.e. 'A' or 'B' A
7.
Does it attract the general condition? If yes, please specify No
8.
Does it attract the specific condition? If yes, please specify No
9.
Location of the projectstarting from Songir Village, Dhule Taluka (Dhule District) to Visarwadi Village, Navapur Taluka (Nandurbar District)
Shape of the project landBlock (Polygon)
Uploaded GPS fileAnnexure-GPS file      
Uploaded copy of survey of India ToposheetAnnexure-Survey of india toposheet
Plot/Survey/Khasra No.--
Town / VillageSongir, Sonadale, Dangurne, Darana, Dalwade P.S., Chimthane, Salwe, Methi, Kampur, Vikhram, Vikhurle, Mandal, Dondaicha-Warwade(Mc-1), Rami, Dhawde, Khokrale, Nyahali, Ghotane, Ranale, Vawad, Chaupale
State of the projectMaharashtra
Details of State of the project
S.no State Name District Name Tehsil Name
(1.)MaharashtraNandurbarNandurbar
(2.)MaharashtraNandurbarNawapur
(3.)MaharashtraDhuleSindkhede
(4.)MaharashtraDhuleDhule
10.
Nearest railway station along with distance in kms Nandurbar Railway station, 1.30 km
Nearest airport along with distance in kms Dhule Airport, 19 km
11. Nearest Town/City/District Headquarters along with distance in kms Nandurbar , 5.41 km
12. Village Panchayats, Zila Parishad, Muncipal Corporation, Local body (Complete postal address with telephone nos. to be given) The project is under the jurisdiction of National Highways Authority of India (NHAI)
13. Name of the Applicant Vasant
14. Registered Address Vasant Raj, 510-B/36 , E-Ward, Ghatge Colony
15.
Address for correspondance:
Name of the Company NHAI PIU KOLHAPUR
Name of the Applicant Vasant
Designation (Owner/ Partner/ CEO) GM(Tech)&Project Director
Pin code 416003
E-mail piukolhapur@nhai.org
Telephone No. 231-2668868
Fax No. 231-
Copy of documents in support of the competence/authority of the person making this application to make application on behalf of the User Agency . NIL
16.
Details of Alternative Sites examined, if any. Location of these sites should be shown on a toposheet No
17. Whether part of Interlinked projects? No
18. Whether separate application of Interlinked project has been submitted? N/A
19.
If Yes, MoEF file numberN/A
Date of submissionN/A
20. If No, Reason N/A
21.
Whether the proposal involves Approval/ Clearance under: if yes, details of the same and their status to be given
(i) Whether the proposal involves approval/clearance under the Forest (Conservation) Act,1980?Yes
StatusApplication for Forest Clearance yet to be submitted
(ii) Whether the proposal involves approval/clearance under the wildlife (Protection) Act,1972?No
(iii) Whether the proposal involves approval/clearance under the C.R.Z notification, 2011?No
22.
Whether there is any Government Order/Policy relevant/relating to the site?No
23.
Whether any Forest Land Involved?Yes
Area of Forest land Involved (hectares)15 ha.
24.
Whether there is any litigation pending against the project and/or land in which the project is proposed to be set up?No
(a) Name of the CourtN/A
(b) Name of the Sub courtN/A
(c) Case No.N/A
(d) Orders/directions of the court, if any and relevance with the proposed projectN/A
(II) Activity
1 Construction, operation or decommissioning of the Project involving actions, which will cause physical changes in the locality (topography, land use, changes in water bodies, etc.)
S.No Information/Checklist confirmation Yes/No Details there of (with approximate quantities/rates, wherever possible) with source of information data
1.1 Permanent or temporary change in land use, land cover or topography including increase in intensity of land use (with respect to local land use plan) Yes Land use change is partially applicable as there is 15-20 m of available Right of Way (ROW) which would require additional land acquisition and also the area falling under the proposed bypasses which majorly passes through agricultural land.
1.2 Clearance of existing land, vegetation and buildings? Yes Partial vegetation clearance will take place as some part of the highway traverses through the forest (15 Ha approximately), agricultural land and natural vegetation. Detailed enumeration will be carried out during EIA.
1.3 Creation of new land uses? Yes Additional Right of Way (ROW) is required as the available ROW is 15-20 m. Additional land is required for the proposed bypasses.
1.4 Pre-construction investigations e.g. bore houses, soil testing? Yes Preconstruction investigations viz., topographical surveys, traffic survey, sub grade soil investigation, subsurface investigation using bore logs for structures, Geophysical investigation, existing pavement composition, existing road strength and roughness surveys, Groundwater investigations, Laboratory testing of material will be carried out during pre-construction stage.
1.5 Construction works? Yes 6.87 sq. km/ 687 ha of land will be utilised for construction works.
1.6 Demolition works? Yes There is a possibility of demolition work of existing structures within the project alignment prior to the construction. (The extent of demolition will be quantified in EIA).
1.7 Temporary sites used for construction works or housing of construction workers? Yes Temporary sites for construction works, material storage and housing of construction workers will be provided with prior investigation by properly addressing environmental concerns.
1.8 Above ground buildings, structures or earthworks including linear structures, cut and fill or excavations and fill or excavations Yes Above ground structures like toll plaza, administrative buildings, weighing stations, parking areas & rest areas and Office cum Residential complex of PIU are proposed.
1.9 Underground works including mining or tunnelling? No
1.10 Reclamation works? No
1.11 Dredging? No
1.12 Offshore structures? No
1.13 Production and manufacturing processes? No
1.14 Facilities for storage of goods or materials? Yes Temporary facilities shall be provided during the construction phase.
1.15 Facilities for treatment or disposal of solid waste or liquid effluents? Yes Solid waste will be generated from demolition activities and other allied activities in the construction phase and during the operation phase, waste will be generated from proposed structures like toll plaza, administrative buildings, weighing stations, parking areas & rest areas and office cum residential complex of PIU. Waste management during construction and operational phase shall be done as per Waste Management Rules, 2016. Details will be furnished in EIA report.
1.16 Facilities for long term housing of operational workers? No
1.17 New road, rail or sea traffic during construction or operation? No
1.18 New road, rail, air water borne or other transport infrastructure including new or altered routes and stations, ports, airports etc? No
1.19 Closure or diversion of existing transport routes or infrastructure leading to changes in traffic movements? Yes Wherever the road is getting expanded or the route has heavy traffic congestion, there may be diversion depending on the engineering brief.
1.20 New or diverted transmission lines or pipelines? Yes Shifting of utilities such as power stations, transmission towers, communication towers, etc. which lie within the proposed RoW. Utility shifting quantification will be furnished in EIA.
1.21 Impoundment, damming, culverting, realignment or other changes to the hydrology of watercourses or aquifers? Yes Provision for culverts and bridges is made to prevent the change in natural watercourse
1.22 Stream crossings? Yes The project will cross the Amravati river near Dondaicha Village and Buria river at Chimthana.
1.23 Abstraction or transfers of water from ground or surface waters? No
1.24 Changes in water bodies or the land surface affecting drainage or run-off? Yes Changes in existing drainage pattern are expected due to activities like cutting, filling, construction activities. However, Natural drainage pattern shall be maintained throughout the project by providing necessary cross drainage structures.
1.25 Transport of personnel or materials for construction, operation or decommissioning? Yes Demand of Personnel & construction materials will be fulfilled from nearby sources / areas.
1.26 Long-term dismantling or decommissioning or restoration works? No
1.27 Ongoing activity during decommissioning which could have an impact on the environment? No
1.28 Influx of people to an area in either temporarily or permanently? Yes Temporarily 200 labours shall be employed per day.
1.29 Introduction of alien species? No
1.30 Loss of native species or genetic diversity? Yes Loss of native species or genetic diversity to be determined during the Ecological survey.
1.31 Any other actions? No
2 Use of Natural resources for construction or operation of the Project (such as land, water, materials or energy, especially any resources which are non-renewable or in short supply):
S.No Information/Checklist confirmation Yes/No Details thereof (with approximate quantities/rates, wherever possible) with source of information data
2.1 Land especially undeveloped or agricultural land (ha) Yes 3555200 sq.m of land is agricultural
2.2 Water (expected source & competing users) unit: KLD Yes Water will be purchased. Details will be furnished in EIA report.
2.3 Minerals (MT) Yes The highway construction will require minor minerals like stones, gravel, ordinary clay, ordinary sand, limestone, boulders, kankar, murum, brick earth, bentonite, road metals. As per MINES AND MINERALS (DEVELOPMENT AND REGULATION) ACT, 1957, excavation of minor minerals during construction of roads shall be executed after prior permit.
2.4 Construction material – stone, aggregates, sand / soil (expected source – MT) Yes Material Source Aggregate 1510295 (CUM) Steel 11277 (MT) Cement 92093 (MT) Bitumen 32765 (MT)
2.5 Forests and timber (source – MT) No
2.6 Energy including electricity and fuels (source, competing users) Unit: fuel (MT),energy (MW) Yes LSD D.G sets shall be used for power for onsite construction, wherever grid power supply is not available.
2.7 Any other natural resources (use appropriate standard units) No
3 Use, storage, transport, handling or production of substances or materials, which could be harmful to human health or the environment or raise concerns about actual or perceived risks to human health
S.No Information/Checklist confirmation Yes/No Details thereof (with approximate quantities/rates, wherever possible) with source of information data
3.1 Use of substances or materials, which are hazardous (as per MSIHC rules) to human health or the environment (flora, fauna, and water supplies Yes LSD, lubricants, paints, etc. shall be required for which necessary safety & environmental protection measures would be devised in Environmental Management Plan.
3.2 Changes in occurrence of disease or affect disease vectors (e.g. insect or water borne diseases) No
3.3 Affect the welfare of people e.g. by changing living conditions? Yes It is expected that the construction of proposed highway shall lead to spur economic development around the project corridor.
3.4 Vulnerable groups of people who could be affected by the project e.g. hospital patients, children, the elderly etc. Yes Detail impact assessment will be a part of ESIA.
3.5 Any other causes No
4 Production of solid wastes during construction or operation or decommissioning (MT/month)
S.No Information/Checklist confirmation Yes/No Details thereof (with approximate quantities/rates, wherever possible) with source of information data
4.1 Spoil, overburden or mine wastes Yes Waste material generation during the course of an excavation, quarrying, operation and construction is expected for which proper disposal measures shall be ensured.
4.2 Municipal waste (domestic and or commercial wastes) Yes 50kg of municipal waste is expected to be generated during construction considering 200 labours. During operation phase, the municipal solid waste generated from the amenities proposed along the alignment.
4.3 Hazardous wastes (as per Hazardous Waste Management Rules) No
4.4 Other industrial process wastes No
4.5 Surplus product No
4.6 Sewage sludge or other sludge from effluent treatment No
4.7 Construction or demolition wastes Yes There is a possibility of demolition work of existing structures coming along the project alignment prior to the construction. (Quantification of wastes will be done during EIA)
4.8 Redundant machinery or equipment No
4.9 Contaminated soils or other materials No
4.10 Agricultural wastes No
4.11 Other solid wastes No
5 Release of pollutants or any hazardous, toxic or noxious substances to air(Kg/hr)
S.No Information/Checklist confirmation Yes/No Details thereof (with approximate quantities/rates, wherever possible) with source of information data
5.1 Emissions from combustion of fossil fuels from stationary or mobile sources Yes Emission of SOX, NOX, CO, PM10 and PM2.5 from DG sets and construction vehicles are expected. (Quantification will be presented in EIA).
5.2 Emissions from production processes No
5.3 Emissions from materials handling including storage or transport Yes Emission of SOX, NOX, CO, PM10 and PM2.5 from construction vehicles and fugitive dust emission from material handling is expected. (Quantification will be presented in EIA).
5.4 Emissions from construction activities including plant and equipment Yes Emission of SOX, NOX, CO, PM10 and PM2.5 from DG sets, construction vehicles and handling of construction materials is expected. (Quantification will be presented in EIA)
5.5 Dust or odours from handling of materials including construction materials, sewage and waste Yes Fugitive dust emission from material handling, construction vehicles is expected. Odour from sewage and municipal waste during construction. (Quantification will be presented in EIA)
5.6 Emissions from incineration of waste No
5.7 Emissions from burning of waste in open air (e.g. slash materials, construction debris) No
5.8 Emissions from any other sources No
6 Generation of Noise and Vibration, and Emissions of Light and Heat:
S.No Information/Checklist confirmation Yes/No Details thereof (with approximate quantities/rates, wherever possible) with source of information data
6.1 From operation of equipment e.g. engines, ventilation plant, crushers Yes Equipment like drills, cranes etc. Would be used during construction which would create noise during construction phase. (Details will be presented in EIA)
6.2 From industrial or similar processes Yes Noise and vibration shall be generated during the construction and operation phase as below: Construction phase– Use of construction equipment, plying of trucks on the proposed RoW. Use of DG sets for construction purposes shall lead to noise. Heat would be generated during bitumen heating process. Operation phase- Noise pollution shall be generated due to increased traffic from the proposed RoW.
6.3 From construction or demolition Yes Noise and vibration generation during construction or demolition. (Quantification will be presented in EIA)
6.4 From blasting or piling No
6.5 From construction or operational traffic Yes Heavy Vehicles carrying construction material and other equipment will create noise and vibration; quantification shall be done during EIA stage.
6.6 From lighting or cooling systems No
6.7 From any other sources No
7 Risks of contamination of land or water from releases of pollutants into the ground or into sewers, surface waters, groundwater, coastal waters or the sea:
S.No Information/Checklist confirmation Yes/No Details thereof (with approximate quantities/rates, wherever possible) with source of information data
7.1 From handling, storage, use or spillage of hazardous materials No
7.2 From discharge of sewage or other effluents to water or the land (expected mode and place of discharge) Yes In construction phase, sewage will be generated form at construction sites. Mobile toilets with STP will be provided for the labours. During operation phase, toilets and STPs shall be provided in the amenities area. Details will be furnished in EIA.
7.3 By deposition of pollutants emitted to air into the land or into water Yes Emission of SOX, NOX, CO, PM10 and PM2.5 from construction vehicles and fugitive dust emission from material handling is expected. Proper environmental management plan will be prepared and implemented. Details will be furnished in EIA.
7.4 From any other sources No
7.5 Is there a risk of long term build up of pollutants in the environment from these sources? Yes Emissions are essentially limited to construction phase which spans a time period of 36 months. Hence, there would be no long-term build-up of pollutants.
8 Risk of accidents during construction or operation of the Project, which could affect human health or the environment
S.No Information/Checklist confirmation Yes/No Details thereof (with approximate quantities/rates, wherever possible) with source of information data
8.1 From explosions, spillages, fires etc from storage, handling, use or production of hazardous substances No
8.2 From any other causes Yes During construction phase, accidents may happen if proper measures are not followed. During operation phase, proper signages and speed breakers at appropriate areas should be provided to reduce the risk of accidents.
8.3 Could the project be affected by natural disasters causing environmental damage (e.g. floods, earthquakes, landslides, cloudburst etc)? Yes The project falls under moderate risk Seismic Zone - III. According to the NIDM report of Maharashtra, some areas of Dhule district are drought-prone areas. Also, many villages are identified as flood prone every year. Design of structure will comply with the required IS specification. Proper measures shall be taken in detailed design to minimize the impact of any such disaster. Necessary measures for safeguarding against landslides shall be incorporated during design and construction stage
9 Factors which should be considered (such as consequential development) which could lead to environmental effects or the potential for cumulative impacts with other existing or planned activities in the locality
S.No Information/Checklist confirmation Yes/No Details thereof (with approximate quantities/rates, wherever possible) with source of information data
9.1 Lead to development of supporting utilities, ancillary development or development stimulated   by the project which could have impact on the environment e.g.:
  • Supporting infrastructure (roads, power supply,waste or waste water treatment, etc.)
  • housing development
  • extractive industries
  • supply industries
  • Other
Yes • Proposed project will lead to development of supporting infrastructure (roads, power Supply, waste or waste water treatment, etc.), housing development. • The improvement will especially speed up the freight movement and provide a better access to freight vehicles as a link to the National Highways.
9.2 Lead to after-use of the site, which could have an impact on the environment No
9.3 Set a precedent for later developments Yes Route 3 is a part of the entire stretch of Bharatmala project which shall set precedence for subsequent developments at regional and national levels.
9.4 Have cumulative effects due to proximity to other existing or planned projects with similar effects Yes There is going to be development.
(III) Environmental Sensitivity
S.No Areas Name/Identity Aerial distance (within 15km.) Proposed project location boundary
1 Areas protected under international conventions, national or local legislation for  their ecological, landscape, cultural or other related value
Yes No identified and Notified protected area within 15 km from the project boundary
2 Areas which are important or sensitive for ecological reasons - Wetlands, watercourses or other water bodies, coastal zone, biospheres, mountains, forests Yes Water Body Average aerial distance in km from alignment Baldane Lake 2.20 km Songirpada reservoir lake 2.90 km Keli Lake 0.60 km Hazrat Peer Lake 0.70 km
3 Areas used by protected, important or sensitive species of flora or fauna for breeding, nesting, foraging, resting, over wintering, migration Yes It will be determined in the EIA.
4 Inland, coastal, marine or underground waters No
5 State, National boundaries No
6 Routes or facilities used by the public for access to recreation or other tourist, pilgrim areas Yes • Aner Dam Wildlife Sanctuary at 46.20 kms from Songir. • Laling Fort at 29 kms from Songir. • Toranmal Hill station is at 59.08 km from Nandurbar. • Torna Devi temple (Tornai) 58.62 km from Nandurbar.
7 Defence installations No
8 Densely populated or built-up area Yes Chimthana, Methi, Vikharan, Ranipura, Dondaicha, Dhavade, Nyahali, Dhandane, Ranala, Vavad, Devmogra, Dekwad, Bhadwad, Nimboni, Visarwadi
9 Areas occupied by sensitive man-made land uses (hospitals, schools, places of worship, community facilities) Yes To be determined during EIA survey
10 Areas containing important, high quality or scarce resources.(ground water resources,surface resources,forestry,agriculture,fisheries,tourism,minerals) No
11 Areas already subjected to pollution or environmental damage.(those where existing legal environmental standards are exceeded) No
12 Areas susceptible to natural hazard which could cause the project to present environmental problems (earthquakes, subsidence, landslides, erosion, flooding or extreme or adverse climatic conditions) similar effects Yes According to the NIDM report of Maharashtra, some areas of Dhule district are drought-prone areas. Also, many villages are identified as flood prone every year
(IV) Proposed Terms of Reference for EIA studies
1 Uploaded Proposed TOR File Annexure-TOR file
2 Uploaded scanned copy of covering letter Annexure-scanned copy of covering letter
3 Uploaded Pre-Feasibility report(PFR) Annexure-PFR
4 Uploaded additional attachments(only single pdf file) NIL
      Essential Detail Sought : NIL
      Additional Detail Sought : NIL
(V) Undertaking
I hereby give undertaking that the data and information given in the application and enclosures are true to be best of my knowledge and belief and I am aware that if any part of the data and information found to be false or misleading at any stage, the project will be rejected and clearance given, if any to the project will be revoked at our risk and cost.
V.(i)
Name of ApplicantVasant
DesignationGM(Tech)&Project Director
Name of Company (Applicant Name should not be given here)NHAI PIU KOLHAPUR
AddressVasant Raj, 510-B/36 , E-Ward, Ghatge Colony
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