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0- applb INSTRUCTIONS -PLEASE READ CAREFULLY 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 records. The LOCAL GOVERNMENTAL UNIT(LGU)city,county or water management organization 0 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: The above agencies may provide a copy of your completed form to the Minnesota Pollution Control Agency (MPCA). MPCA water quality issues may apply to your proposed project. ATTENTION (From USDA): Any activity including drainage,dredging, filling,leveling or other manipulations, including maintenance, may affect a landuser's eligibility 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 activity. IMPORTANT: Some agencies, including the Corps of Engineers and the MDNR accept this form as a permit application form. If you wish this form to constitute an application to the Corps and/or MDNR 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 activities described herein. I certify that I am familiar with the information contained in this application,and that to the best of my knowledge and belief such information is true, complete and accurate. I further certify that I possess the authority to undertake the proposed activity or I am acting as the duly authorized agent of the applicant. Signature of Applicant Date igenature o 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 information requested below is provided. Agent's Name &Title: Agent's Address: Z% ?j . k e(5216 CTr• , ! 1��2y1� . (��f� N Agent's Telephone: (yv��- S 18 U.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction 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 statements or representations or makes or uses any false writing document knowing same to contain any false, fictitious,or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years, or both.