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/KA/Others/38703/2019   (ii). Name of Project for which Forest Land is required : Change of land use pattern of diverted forest land for achieving the objectives of The Totgars Cooperative Sale Society Ltd., Sirsi along with construction of Ayurvedic Hospital   (iii). Short narrative of the proposal and Project/scheme for which the forest land is required : Request to permit us to use the diverted forest land of Sy.No.47 of Chipgi Village in Sirsi Taluk for achieving the objectives of our Society along with construction of Ayurvedic Hospital.   (iv). State : Karnataka   (v). Category of the Proposal : Others   (vi). Shape of forest land proposed to be diverted : Hybrid   (vii). Estimated cost of the Project(Rupees in lacs) : 700   (viii). Area of forest land proposed for diversion(in ha.): 2.02   (ix). Non-forest land required for this project(in ha.): 0   (x). Total period for which the forest land is proposed to be diverted(in years): 20
A-2. Details of User Agency
  (i). Name : THE TOTGARS COOPERATIVE SALE SOCIETY LTD SIRSI   (ii). Address1 : The Totgars' Cooperative Sale Society Ltd., Market Yard, Sirsi Uttara Kannada District, Karnataka   (iii). Address2 : NIL   (iv). State : Karnataka   (v). District : Uttara Kannada   (vi). Pin : 581402   (vii). Landmark : NIL   (viii). Email address : tss@tssindia.in   (ix). Landline Telephone No. : 8384-236371   (x). Fax No. : 8384-   (xi). Mobile No. : 9008231123   (xii). Website (if any) : NIL   (xiii). Legal status of User Agency : Others
A-3. Details of Person Making Application
  (i). First Name: Raveesh   (ii). Middle Name: Achut   (iii). Last Name: Hegde   (iv). Gender: Male   (v). Designation: GeneralManager   (vi). Address 1: The Totgars Cooperative Sale Society Ltd, Market Yard, Sirsi   (vii). Address 2: NIL   (viii). State: Karnataka   (ix). District: Uttara Kannada   (x). Tehsil: NIL   (xi). Pin: 581402   (xii). Landmark: NIL   (xiii). Email Address: tss@tssindia.in   (xiv). Landline Telephone No.: 8384-236371   (xv). Fax No.: NIL   (xvi). Mobile No.: 9008231123   (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
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
1Approved4015F.No.FCA/11.2/193/KAR/BC/492.022.0216 Jan 200213 Apr 2016
2ApprovedFP/KA/DISP/47/2000F.No. FCA/11.2/193/KAR/BC/492.022.0216 Jan 200213 Apr 2016
Total 4.04 4.04
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.Sirsi2.020
Total2.020
B-2.2 Details of Districts involved
District wise breakup
S.no District Name Forest Land(ha.) Non-Forest Land(ha.)
1.Uttara Kannada2.020
Total2.020
B-2.3 Village wise breakup
Villages wise breakup
S.no Village Forest Land(ha.) Non-Forest Land(ha.)
1Chipagi F.Sy.No.472.020
Total 2.02 0
B-2.4 Component wise breakup
Component wise breakup
S.no Component Forest Land(ha.) Non-Forest Land(ha.)
1Ayurvedic Hospital0.10380
2Herbal Garden0.01870
3Canteen0.01730
4Bore/UG Tank0.0120
5Parking-10.08560
6Ayurvedic Research Centre0.08150
7Auction House0.1280
8Courtyard0.10830
9Warehouse0.08150
10Areca Research Centre0.06340
11Rice Mill0.06340
12Doctors/Nurse Quarters0.03950
13Parking0.02020
14Parking-20.05480
15Way0.00880
16Internal Road & Open space1.13310
Total 2.0199 0
C. Maps of forest land proposed to be diverted
Division 1. : Sirsi
  (i). Area of forest land proposed to be diverted(in ha.) : 2.02   (ii). Nature of the Project: Hybrid   (a). No. of patches : One
Patch wise details
Patch No. Area of Patch(in ha.) Kml File of PatchesTo view KML file on google the same may be downloaded and then open if in google earth install in your computer.
1.0.91075877    View File
  (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).
1.0.82    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: Yes   (a). Copy of map indicating location of alternative examined:
E. Employment likely to be generated
  (i). Whether the Project is likely to generate employment ?: Yes   (ii). Permanent/Regular Employment(Number of persons): 350   (iii). Temporary Employment(Number of person-days): 650
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?: No
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? : Yes   (a). Copy of documentry evidence in support of settlement of rights under the Forest Rights Act,2006 on the forest land proposed to be diverted:
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: Others
Additional information Details
Documents
S.No Documents
Remarks
1Letter of undertaking regarding NPV and Compensatory Afforestation
2No construction work is being under taken at the diverted forest land in F.Sy.No47 of Chipagi village in Sirsi Taluk except erection of compound wall which has been done to comply the conditions laid down by the department while giving in-principle approval for the proposal.
3Stage-|| approval of the Ministry of Forests, Environment & Climate Change for diversion of 2.02ha of forest land in Sy.No.47 of Chipagi village of Sirsi taluk for construction of hospital by the Totgars' Cooperative Sale Society Ltd., Sirsi.
4Approval of the Government of Karnataka for diversion of 2.02ha of forest land in Sy.No.47 of Chipagi village of Sirsi taluk for construction of hospital by the Totgars' Cooperative Sale Society Ltd., Sirsi.
5Component-wise length width break up of all regular shaped components.
6Compliance to EDS.
7Clarification regarding the remark in Additional Information Details/General column.
8GPS readings (Datum:WGS-84; in Degree.decimals of all corners of the diverted forest land as well as at a regular 20 meter interval.
9Approved layout plan in respect of stage -II approved project for diversion of 2.02ha forest land in F.Sy.No.47 of Chipagi village in Sirsi Taluka for construction of 100 bed modern hospital
10Proposed layout plan for re-diversion of 2.02ha forest land in F.Sy.No.47 of Chipagi village in Sirsi taluka for multipurpose project involving construction of Areca nut Auction House, Ayurvedic Hospital, Warehouse, Rice Mill, Ayurvedic Research Centre, Areca nut Research Centre etc.,