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Example of A Geohazard Certifcation Application Form

The document is a GeoHazard Certification Application Form that must be completed for each project, requiring mandatory fields to be filled out in block letters. It includes details about the proponent, project specifics, geographic coordinates, and documentation requirements such as photos and a vicinity map. A letter request to the Office of the MGB Regional Director must accompany the application, along with a fee of Php 50.00.

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Josephine Templa-Jamolod
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16 views2 pages

Example of A Geohazard Certifcation Application Form

The document is a GeoHazard Certification Application Form that must be completed for each project, requiring mandatory fields to be filled out in block letters. It includes details about the proponent, project specifics, geographic coordinates, and documentation requirements such as photos and a vicinity map. A letter request to the Office of the MGB Regional Director must accompany the application, along with a fee of Php 50.00.

Uploaded by

Josephine Templa-Jamolod
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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GEOHAZARD CERTIFICATION

APPLICATION FORM ISO FORM NO.


Instructions:
1. Accomplish this form in one (1) copy per project.
2. Type or print all entries in BLOCK or CAPITAL LETTERS.
3. Provide two (2) contact numbers on the “CONTACT DETAILS” portion.
4. All fields which are marked with an asterisk (*) are mandatory.
5. This application form should be accompanied by a letter request addressed to the Office of the MGB
Regional Director.
Date: May 26, 2020 MGB-IX Doc No.
*PROPONENT’S DETAILS
Name ext.
Title *First Name *Middle Initial *Surname
(e.g., Jr., II)
Mr. Juan Marcelo S. Dela Cruz
*Designation: Engineer III
*Office: Mines and Geosciences Bureau IX
*Office Pasonanca Park, Barangay Pasonanca
Address: Zamboanga City, Zamboanga del Sur
*Contact No. (+63) 9123456789 *Landline No. 992 2194

Email Address juanmd@gmail.com Fax No: 993 5765

*PROJECT DETAILS

*Project Title: Concreting of Farm to Market Road

*Address of the Proposed Site


Purok/Sitio Barangay City/Municipality Province
Purok 3 Paradise Diplahan Zamboanga Sibugay
For Building Projects:
Geographic Coordinates Surveyor’s/Geometric
Latitude Longitude Elevation (m) Measurements
GC Source (e.g., Google
Earth, Google Map), if taken Lot Area
from GPS device or field
survey, please indicate the Unit (m2, Ha)
datum used.
Remarks
WGS 1984

Luzon 1911

For projects such as road developments, bridge, pipeline, drainage system, and any other linear-featured projects.

Geographic Coordinates Surveyor’s/Geometric


Start Measurements
Latitude Longitude Elevation (m)
Linear Extent 5
7.764620 122.974758
GC Source (e.g., Google
Earth, Google Map), if taken or or 125
from GPS device or field 7 45 52.73 122 58 29.10 Unit (ft, m, km) Km
survey, please indicate the
datum used. End Other Specifications
Latitude Longitude Elevation (m)
WGS 1984 The farm to market road will be
constructed 2 meters above the
Luzon 1911 ground level with systematic
7.944620 123.214758 225
drainage canals.
*DOCUMENTATION OF THE PROJECT SITE

Please provide good quality photos and a vicinity map of the proposed site/area below.
For BUILDING PROJECTS, provide the orientation of the photos provided (e.g., looking north, east, west or south).
For LINEAR-FEATURED PROJECTS, provide photos of the starting and the ending point of the project site.

INSERT PHOTOS HERE

Orientation:

INSERT PHOTOS HERE

Orientation:
For the Vicinity Map of the proposed site, please enclose it with this application form.

I hereby certify that the information given and all statements are true and correct.

May 26, 2020

PROPONENT’S SIGNATURE DATE

As per DAO No. 2005-08, providing for new fees and charges for various services of the Mines and
Geosciences Bureau, page 3, letter-request for certification has a corresponding fee of Php. 50.00.

For further queries, please contact us at this Tel No. (62) 992-2194 or Geosciences Operation Center
mobile no. +639956248059, or you may email at georegion9@gmail.com.

*Use a separate page for additional photo documentation

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