FORM - A
Form for seeking prior approval of Central Government under section 2 of the Forest(Conservation) Act,1980 for Diversion of fresh forest area
PART - I
(To be filled up by User Agency)
A. General Details
A-1. Project Details
  (i). Proposal No. : FP/GA/ROAD/19776/2016   (ii). Name of Project for which Forest Land is required : Four Laning of existing Goa/Karnatalka border-Panaji Goa section of NH-4A from Km97.000 to Km153.075 in the state of Goa on BOT (Toll) basis under NHDOIII (Anmod to PanajiSection))   (iii). Short narrative of the proposal and Project/scheme for which the forest land is required : Four Laning of existing Goa/Karnatalka border-Panaji Goa section of NH-4A from Km97.000 to Km153.075 in the state of Goa on BOT (Toll) basis under NHDPIII (Anmod to PanajiSection)   (iv). State : Goa   (v). Category of the Proposal : Road   (vi). Shape of forest land proposed to be diverted : Linear   (vii). Estimated cost of the Project(Rupees in lacs) : 120000   (viii). Area of forest land proposed for diversion(in ha.): 31.53   (ix). Non-forest land required for this project(in ha.): 59.21   (x). Total period for which the forest land is proposed to be diverted(in years): 100
A-2. Details of User Agency
  (i). Name : PUBLIC WORKS DEPARTMENT   (ii). Address1 : EXECUTIVE ENGINEER WD XV(NH) PWD PONDA   (iii). Address2 : NIL   (iv). State : Goa   (v). District : North Goa   (vi). Pin : 403401   (vii). Landmark : GOVT BUILDING PONDA TISK   (viii). Email address : ee15-pwd.goa@nic.in   (ix). Landline Telephone No. : 832-2313024   (x). Fax No. : 832-2313024   (xi). Mobile No. : 9370699881   (xii). Website (if any) : www.pwd.gov.in   (xiii). Legal status of User Agency : State Government
A-3. Details of Person Making Application
  (i). First Name: Mohan   (ii). Middle Name: S   (iii). Last Name: Karki   (iv). Gender: Male   (v). Designation: Executive Engineer   (vi). Address 1: Executive Engineer WD XV(NH) PWD Ponda Goa   (vii). Address 2: NIL   (viii). State: Goa   (ix). District: North Goa   (x). Tehsil: Tiswadi   (xi). Pin: 403001   (xii). Landmark: NIL   (xiii). Email Address: ae1eexv@gmail.com   (xiv). Landline Telephone No.: 832-2313024   (xv). Fax No.: 08322313024   (xvi). Mobile No.: 9168694726   (xvii). Copy of documents in support of the competence/authority of the person making this application to make application on behalf of the User Agency:
B. Details of land required for the Project
B-1. Details of proposal seeking prior approval of Central Government under the Act for diversion of forest land for the Project already submitted in the past
List of proposal submitted in Past
S.no Proposal Status. Proposal No. Moef File No. Area Proposed for Diversion(Ha.) Area Diverted(Ha.) Date of In-Principle Approval Date of Final Approval
NIL
B-2. Details of forest land proposed to be diverted
B-2.1 Details of Divisions involved
Details of Divisions involved
S.no Division Name Forest Land(ha.) Non-Forest Land(ha.)
1.North31.5359.21
Total31.5359.21
B-2.2 Details of Districts involved
District wise breakup
S.no District Name Forest Land(ha.) Non-Forest Land(ha.)
1.North Goa31.5349.85
1.South Goa09.36
Total31.5359.21
B-2.3 Village wise breakup
Villages wise breakup
S.no Village Forest Land(ha.) Non-Forest Land(ha.)
1Mollem14.160.02
2Collem0.060
3Sangod12.270.77
4Dharbandora4.894.01
5Usgao0.155.22
6Piliem04.67
7Bandora08.71
8Priol07.29
9Velinga00.31
10Cuncolim00.69
11Cundaim04.77
12Boma07.94
13Adcolna05.45
14Corlim05.41
15Ella03.95
Total 31.53 59.21
B-2.4 Component wise breakup
Component wise breakup
S.no Component Forest Land(ha.) Non-Forest Land(ha.)
1Road31.5359.2059
Total 31.53 59.2059
C. Maps of forest land proposed to be diverted
Division 1. : North
  (i). Area of forest land proposed to be diverted(in ha.) : 31.53   (ii). Nature of the Project: Linear   (b). No. of Segments : One
Segment wise details
Segments Segment Area(in ha.) Kml File of Segments
(To view KML file on google the same may be downloaded and then open if in google earth install in your computer).
1.31.53    View File
  (iii). Copy of Survey of India Toposheet indicating boundary of forest land proposed to be diverted:   (iv). Scanned copy of the Geo-referenced map of the forest land proposed to be diverted prepared by using GPS or Total Station:
D. Justification for locating the Project in forest land and details of alternatives examined:
  (i). Copy of note containing justification for locating the Project in forest land:   (ii). Whether a copy of map indicating location of alternative examine is required to be provided: No   (a). Reason for not providing such map: Up-gradation of Existing Road
E. Employment likely to be generated
  (i). Whether the Project is likely to generate employment ?: Yes   (ii). Permanent/Regular Employment(Number of persons): 10   (iii). Temporary Employment(Number of person-days): 109500
F. Displacement of People due to the Project, if any
  (i). Whether Project involves displacement?: No
G. Details of Cost-Benefit analysis for the Project
  (i). Whether the Project requires Cost-Benefit analysis?: Yes   (a). Copy of Cost-Benefit analysis:
H. Status of Environmental Clearance
  (i). Whether the Project requires Clearance under the Environment (Protection) Act 1986 ? : No
I. Status of Wildelife Clearance
  (i). Whether the Project or a part thereof is located in any Protected Area or their Eco sensitive zone? : No
J. Applicability of special provisions governing Scheduled Areas
  (i).Whether the Project or a part thereof is located in a Scheduled Area? : No
K. Status of settlement of rights under the Forest Rights Act,2006 on the forest land proposed to be diverted
  (i). Whether the process for settlement of Rights under the Forest Rights Acts 2006 on the forest land proposed to be diverted has been completed? : No
L. Details of land identified for Compensatory Afforestation
  (i). Whether non-forest or Revenue forest land is required to be provided by User Agency?: No   (ii). Whether the area of non-forest land or Revenue forest land required to be provided by User Agency for raising Compensatory Afforestation is less than area of forest land proposed to be diverted ?: No   (iii) . Reason for not providing Non-Forest Land: Central Govt. Project
Additional information Details
Documents
S.No Documents
Remarks
1Administrative Sanction
2Typical Cross Sections of the project Road
3Index Map of the Project Road
4Brief Note on the Project
5Document Verification Certificate
6Unqualified Commitment certificate
7Survey of India TopoSheet No - D43C3
8No violation of Forest Conservation Act
9EIA exemption certificate from the Project Proponent
10Gramsabha Exemption Certificate from the Project Proponent
11Cost of Felling of Trees
12Compensatory Afforestation Certificate
13Archeological Importance Certificate
14Sr. No -2 Darbandora
15Sr. No -57 Darbandora
16Sr. No -95 Darbandora
17Sr. No -100 Darbandora
18Sr. No -207 Darbandora
19Sr. No -12 Molem
20Sr. No -21 Molem
21Sr. No -9 Sangod
22Sr. No -15 Sangod
23Sr. No -27 Sangod
24Sr. No -30 Sangod
25Sr. No -252 Usgaon
26Sr. No -21 Darbandora
27Initial Social Impact Assessment
28Exemption of Environment Clearance
29Exemption of Gram Sabha
30with reference to letter dated 12/08/2016 and 24/10/2016.
31Cost benefit Analysis
32Revised Form - A
33Sr. No-13-1 Molem
34Sr. No-13-1-A Molem
35Sr.NO- 16-1 Sangod
36Sr.NO- 17-1 Sangod
37Sr.NO- 27-1 Sangod
38Sr.NO- 30-1 Sangod
39Sr.NO- 37-1 Sangod
40Sr.NO- 57-1 Sangod
41Sr.NO- 34-1 Colem
42Sr.NO- 34-2 Colem
43Sr.NO- 34-3 Colem
44Sr.NO- 13-2 Molem
45Sr.No- 13-3 Molem
46Sr.No- 13-4 Molem
47Sr.No- 14-1 Molem
48Sr.No- 14-2 Molem
49Sr.No- 15-1 Molem
50Sr.No- 16-1 Molem
51Sr.No- 17-1 Molem
52Sr.No- 17-1-A Molem
53Sr.No- 17-2 Molem
54Sr.No- 22-1 Molem
55Sr.No- 22-1-A Molem
56Sr.No- 22-1 Dharbandora
57Sr.No- 22-2 Dharbandora
58Sr.No- 73-1 Dharbandora
59Sr.No- 93-1 Dharbandora
60Sr.No- 98-1 Dharbandora
61Sr.No- 207-1 Dharbandora
62Revised Forest Area Statement
63Revised Non Forest Area Statement
64Net Present Value certificate
65Minimum Demand Certificate
66Revised forest area statement
67Non forest area statement
68Undertaking for FRA
69Revised Plan
70Covering letter for submission of revised documents
71Revised Cost benefit analysis
72Compliances to the observations raised by Regional Office, Bangalore