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AUG-27-2003 12:01 MINNEHAHA CREEK WATERSHED 6124710682 P.03iO3 °FP1 INSTRUCTIONS-MAU RIECAD CAUJULY A copy of this form,with oapies of all plans,drawings,eta...abould be sent to ewh agency indicated below. Please check the appropriate spaces below to show everywhere you ace sending this form.Remember to keep a copy for your records. The LOCAL GOVERNMENTAL UNIT(LGU)city,county or water management organization The SOIL&WATER CONSERVATION DISTRICT _ HENNEPIN SWCD CARVER SWCD hgNNESOTA DEPARTMENT OF NATURAL RESOURCES(MDNR)Regional-Office US ARMY CORPS OFENGINEERS(ACOS)at:Dept of the Army,Corps of Engineers,St Paul District ATTN.CO-R, 190 Fifth St.East,St Paul,MN 55101-1638 Note,The above agencies may provide a copy of your completed fozm to the Minnesota Pollution Control Agency(MPCA).MPCA water quality issues may apply to yaw proposed project ATTENTION(From USDAI.,Any activity inchdag drainage,dredging,filling,leveling or other manipulations, including maintenance,may affect a laudaser's eligibility for USDA benefits under the 1985 Food Security Act as amended Check with your local USDA office to request and complete Form A33-1026 prior to initiating activity. EWPORTANT:Some agencies,including the Corps of Engineers and the MDNR accept this farm as a permit application form.if you wish this form to constitute on application to the Corps m mor MDNR for any necessary permits for your projects please arefcrlly read the following information and sign whore JrAcated. Application is hemby made for a permit to authorize the activities described herein.I certify that I am familiar 4thetion contained in this application,and that to the best of my knowledge and beliefsuch s ,cvmpleta and aecurate,l fiuther certify the#I possess the authority to undertake the proposed as the duly authorized agent of the applicant. S" o pph Date Signature of Agent Date Note: a lion must be signed by the person who desired to undertake then proposed.activity (Applicant)or it may be signed by a duly authorize a,gaint if the information requested below is provided. Agent's Name&Title: b Agent s Address• Z kj1.l rte- ,1J t le- Agent's Telephone: 18 U.S.C.Section 1001 provides that:Whoever,in any manner within the jurisdiction of any deparbmeat or agency of the United States knowingly and willfully Alsifies,conceals,or covers up by any trick,scheme,or device a material fact or makes say false,fictitious or fisudulent statements or representations or makes or uses any false writing document knowing same to contain any false,fictitious,or flaardalent statement of entry,shall be fined not more than.S 10,000 or imprisoned not more thea five years,or both, TnTAI D M-2