Appl/activites affecting water resources

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Project Name and/or Number: PART FOUR: Aquatic Resource impact*' Summary If your proposed project involves a direct or indirect impact to an aquatic resource (wetland, lake, tributary, etc.) identify each impact in the table below. Include all anticipated impacts, including those expected to be temporary. Attach an overhead view map, aerial photo, and/or drawing showing all of the aquatic resources in the project area and the locations) of the proposed impacts. Label each aquatic resource on the map with a reference number or letter and identify the impacts In the following table. Aquatic Type of Impact Duration of Existing Plant County,Major Aquatic Resource Resource Type Community(fill,excavate, Impact Overall Size of Watershed (wetland,lake, #, 2 Type(s)in ID(as noted on drain,or Permanent(P) Size of impact Aquatic and Bank overhead view) remove or Temporary Resource a 4 Service Area# tributary etc.) Impact Area s vegetation) (T)-' of Impact Area A Wetland Fill P 189 Sq Ft Unknown Wet Meadow Hennepin, W#20,BSA#7 lIf impacts aretemporary;enter the duration of the Impacts in days next to the"T". For example,a project with a temporary access fill that would be removed after 220 days would be entered`T(220)". 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 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 along the flowifne of the stream followed by the area impact In parentheses). For example,a project that impacts 50 feet of a stream that is 6 feet wide would be reported as 50 ft(300 square feet). 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". 4Use Wetland Plants and Plant Community Types of Minnesota and Wisconsin 3'd Ed.as modified in MN Rules 8420.0405 Subp.2. SRefer to Major Watershed and Bank Service Area maps in MN Rules 8420.0522 Subp.7. If any of the above identified impacts have already occurred, identify which impacts they are and the circumstances associated with each: PART FIVE: Applicant Signature ❑ Check here if you are requesting a pre-application consultation with the Corps and LGU based on the information you have provided. Regulatory entitles will not initiate a formal application review if this box is checked. By signature below, I attest that the information in this application is complete and accurate. I further attest that I possess the authority to undertake the work described herein. Signature: Date: I hereby authorize to act on my behalf as my agent in the processing of this application and to furnish,upon request, supplemental information in support of this application. 1 The term"impact"as used in this joint application form is a generic term used for disclosure purposes to Identify activities that may require approval from one or more regulatory agencies. For purposes of this form it is not meant to Indicate whether or not those activities may require mitigation/replacement. Minnesota Interagency Water Resource Application Form February 2014 Page 4 of 11