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~ y + �� . . 5 w-.�� applb INSTRUCTIONS-PLEASE READ CA F,FULLY A copy of this form, with copies of all plans,drawings,etc... should be sent to each agency indicated below. Please check the appropriate spaces below to show everywhere you are sending this form. Remember to keep a copy for your cords. The LOCAL GOVERNMENTAL LTNIT(LGLn city,county or water management organizarion The SOIL&WATER CONSERVATiON DISTRICT _ HENNEPIN SWCD CARVER SWCD MINNESOTA DEPARTMENT OF NATURAL RESOURCES (MDNR)Regional Office US ARMY CORPS OF ENGINEERS(ACOE) at: Dept. of the Army,Corps of Engineers, St.Paul District-ATTN: CO-R, 190 Fifth St. East,St. Paul,MN 55101-1638 Note: Tiie above agencies may provide a copy of your comnleted form to the Minnesota Pollution Control Agency(MPCA). MPCA water quality issues may apply to your proposed project. ATTENTION(From USDAI: Any acrivity including drainage,dredging,filling, leveling or other manipulations, including maintenance,may affect a landuser's eligibilihj for USDA benefits under the 1985 Food Security Act as amended. Check with your local USDA office to request and complete Form AD-1026 prior to initiating acrivity. IMPORTANT: Some agencies, including the Corps of Engineers and the MDNR accept this foim as a pernut applicarion form.If you wish this form to consritute an applicarion to the Corps and/or IvIDNR for any necessary permits for your projects please carefully read the following information and sign where indicated. Application is hereby made for a permit to authorize the acrivities described herein. I certify that I am familiar with the infoxmarion contained in this applicarion,and that to the best of my knowledge and belief such _ information is true,complete and accurate. I further certify that I pos u ' �to undertake the proposed activity or I am acting as the duly authorized agent of th �- �� Signature of Applicant Date S of gent Date Note: The application must be signed by the person who desired to undertake the proposed activity (Applicant)or it may be signed by a duly authorize agent if the infortnation requested below is provided. Agent's Name&Title: �/�'�i�� ' � 1�� 1�}�� AgenYs Address:_ _ �� Y� ��rl�� M� ��3�7f AgenYs Telephone�.�{ �� 2� � 1 �� r- 18 U.S.C. Section 1001 provides that: Whoever,in any manner withir.the jurisdic:ior.of any department or agency of the United States knowingly and willfully falsifies, conceals, or covers up by any trick,scheme, or device a material fact or makes any false, fictitious or fraudulent statemen�s or representations or makes or uses any false writing document Imowing same to contain any false, fictifious,or fraudulent statement or entry,shall be fined not more than$10,000 or imprisoned not more than five years,or both.