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Project Name and/or Number: 2018-127 <br /> PART FOUR: Aquatic Resource Impact' Summary <br /> If your proposed project involves a direct or indirect impact to an aquatic resource (wetland, lake, tributary, etc.) identify each <br /> impact in the table below. Include all anticipated impacts, including those expected to be temporary. Attach an overhead view <br /> map, aerial photo, and/or drawing showing all of the aquatic resources in the project area and the location(s) of the proposed <br /> impacts. Label each aquatic resource on the map with a reference number or letter and identify the impacts in the following table. <br /> Type of County,Major <br /> Aquatic Duration of <br /> Aquatic Impact(fill, Existing Plant Watershed#, <br /> Resource Impact Overall Size of <br /> Resource ID (as excavate, Size of Community and Bank <br /> Type Permanent(P) Aquatic <br /> noted on drain,or Impact Type(s) in Service Area# <br /> overhead view) (wetland,lake, remove or Temporary Resource Impact Area' of Impact <br /> tributary etc.) (T)' <br /> vegetation) Areas <br /> 'If impacts are temporary;enter the duration of the impacts in days next to the"T". For example,a project with a temporary access fill that <br /> would be removed after 220 days would be entered"T(220)". <br /> 2lmpacts less than 0.01 acre should be reported in square feet. Impacts 0.01 acre or greater should be reported as acres and rounded to the <br /> nearest 0.01 acre. Tributary impacts must be reported in linear feet of impact and an area of impact by indicating first the linear feet of impact <br /> along the flowline of the stream followed by the area impact in parentheses). For example,a project that impacts 50 feet of a stream that is 6 <br /> feet wide would be reported as 50 ft(300 square feet). <br /> 3This is generally only applicable if you are applying for a de minimis exemption under MN Rules 8420.0420 Subp.8,otherwise enter"N/A". <br /> 4Use Wetland Plants and Plant Community Types of Minnesota and Wisconsin 3rd Ed.as modified in MN Rules 8420.0405 Subp.2. <br /> 'Refer to Major Watershed and Bank Service Area maps in MN Rules 8420.0522 Subp.7. <br /> If any of the above identified impacts have already occurred, identify which impacts they are and the circumstances associated <br /> with each: <br /> PART FIVE: Applicant Signature <br /> n Check here if you are requesting a pre-application consultation with the Corps and LGU based on the information you have <br /> provided. Regulatory entities will not initiate a formal application review if this box is checked. <br /> By signature below, I attest that the information in this application is complete and accurate. I further attest that I possess the <br /> authority to undertake the work described herein. <br /> Signature: Date: <br /> I hereby authorize Wayne Jacobson to act on my behalf as my agent in the processing of this application and to furnish, upon <br /> request,supplemental information in support of this application. <br /> 1 The term "impact"as used in this joint application form is a generic term used for <br /> disclosure purposes to identify activities that may require approval from one or more <br /> regulatory agencies. For purposes of this form it is not meant to indicate whether or not <br /> those activities may require mitigation/replacement. <br /> Minnesota Interagency Water Resource Application Form February 2014 Page 4 of 11 <br />