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APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT(33 CFR 325) OMB APPROVAL NO.0710-003 Expires Dee 31,2004
<br /> The public burden for this collection of information is estimated to average 10 hours per response,although lite majority of applications should require 5 hours or less. This includes
<br /> the time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and renewing the collection of information. Send
<br /> comments regarding this burden estimate or any other aspect of this collection of information,including suggestions for reducing this burden,to Department of Defense,Washington
<br /> Headquarters Service Directorate of Information Operations and Reports,1215 Jefferson Davis Highway,Suite 1204,Arlington,VA 222024302;and to the Office of Management
<br /> and Budget,Paperwork Reduction Project(0710-0003),Washington,DC 20503. Respondents should be aware that notwithstanding any other provision of law,no person sba0 be
<br /> subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please DO NOT RETURN your form to
<br /> either of these addresses. Completed applications must be submitted to the District engineer having jurisdiction over the location of the proposed activity.
<br /> ' PRIVACY ACT STATEMENT:Authorities:Rivers and Harbors Act,Section 10,33 USC 403;Clean Water Act,Section 404,33 USC 1344;Marine Protection,Research and
<br /> Sanctuaries Act,33 USC 1413,Section 103. Principal purpose:information provided on this form will be nsed in evaluating the application for a permit. Routine uses:This
<br /> information may be shared with the Department of Justice and other Federal,state,and local government agencies. Submission of requested information is voluntary;however,if
<br /> information is not provided the permit application cannot be evaluated nor can a permit be issued.
<br /> ITEMS 1 THROUGH 4 TO BE FILLED IN BY THE CORPS
<br /> I.APPLICATION NO. 2.FIELD OFFICE CODE 3.DATE RECEIVED 4.DATE APPLICATION COMPLETED
<br /> YOU DO NOT NEED TO COMPLETE ITEMS 6-10 and 12-26 in the SHADED AREAS.
<br /> All applicants must complete non-shaded items 5 and 26. if an agent is used,also complete items 8 and 11. This optional Federal form is valid
<br /> for use only when included as part of this entire state application packet.
<br /> ' 5.APPLICANT'S NAME 8.AUTHORIZED AGENT'S NAME AND TITLE(an agent is not required)
<br /> Spring Hill Golf Club Kelly Bopray,President,BES,Inc.
<br /> ' 6.APPLICANTS ADDRESS_ 9:AGENT'S ADDRESS
<br /> 7,APPLICANT'S PHONE NO. 10.AGENT'S PHONE NO.
<br /> 11.STATEMENT OF AUTHORIZATIO f applicable;complete only if authorizing an agent)
<br /> I hereby authorize Kelly Bopray to act on my behalf as my agent in the processing of this application and to furnish,upon
<br /> request,supplemental information in sup o of this p application.
<br /> APPLICANTS SIGNATURE: DATE: Z �
<br /> 12.PROJECT NAME OR T1T ee instructio»s)
<br /> .13;NAME OF WATERBOD ,IF KNOWN(if applicable) 14.PROJECT STREET ADDRESS(if apphc4lile)
<br /> ' 15,LOCATION OF PROJECT
<br /> 16.OTHER LOCA1'JOI DESCItiPTIONS,IF KNOWN see itistructiods)
<br /> 17:DIRECTIONS
<br /> TO THE SrfE; 18:NATURE OF
<br /> DIRACTIVITY
<br /> ' 19.PROJFCTPURPOSE' 20.REASON(S)FORDISCHARGE_
<br /> 21.TYPES OP.MATERIAL BEING DISCHARGED AND THE AMOUNT OP EACELTYPE IN CUBIC YARDS "
<br /> 22.SURFACE AREA
<br /> IId ACRES OF WETLANDS OR OTHER WATERS FILLED
<br /> 23:15 ANY PORTION OF tIIE WORK ALREADY COMPLETE? YES NOT IF YES,DESCRIB)3 COMPL$TED WORK
<br /> 24 ADDRESSES"OE ADJOINING PROPERTY OWNERS
<br /> 25.LIST OF OTHER CERTIFICATIONS OR APPROVAISIDENIALS RECEIVED FROM OTHER FEDERAL,STATE ORZOCAL AGENCIES FOR
<br /> WORK DESCRIBED IN THS APPf.ICATION.
<br /> ' 26. Appile do is hereby made for a permit or permits to authorize the work described in this application. I certify that the information in this
<br /> applicatto is omplete and accurate. I further certify that I possess the authority to undertake the work described herein or am acting as the duly
<br /> authoriz a nt of the applicant.
<br /> i Zi Z6
<br /> I 7/ i0�v" 11 1�`',1 I z
<br /> Signal f pplicant ate Signa re o ge (if art Date
<br /> The ap cation must be signed by the person who desi s to ndertake the proposed activity(applicant),or it may be signed by a duly authorized agent if
<br /> ' the sta ment in Block I I has been filled out and sign I8 U.S.C.Section 1001 provides that:Whoever,in any manner within the jurisdiction of any
<br /> dep ent or agency of the United States knowingly and willfully falsifies,conceaIs,or covers up with any trick,scheme,or disguises a material fact or
<br /> m ce§any false,fictitious or fraudulent statements or representations or makes or uses any false writing or document knowing same to contain any false,
<br /> fictitious or fraudulent statements or entry,shall be fined not more than$10,000 or imprisoned not more than five years or both.
<br /> ' ENG FORM 4345,Jul 97 EDITION OF FEB 94 IS OBSOLETE. (Proponent:CECW-OR)
<br /> Minnesota Local/State/Federal Application Forms for Water/Wetland Projects
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