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NA-02620-02 12.14.00 . <br /> �e',+T"R'eq.,3 'z .j, - •: t a'a 3 '» td5. `* r' r <br /> i�a,�bn <br /> -at°4 eS0 1 L.ocaUState/Federal , ppltcatlonaForms for Water/Wedand Projects <br /> irr esm{= x .i^`�� 8 .% .k .CHS{ ,s ♦ r tt p -'t3'-D s „ a„ °' t <br /> � rQR JIERNpL1ISE OI�ILY <br /> . •wb 3`� .: 5{ t }, <br /> it i,,,r¢§ `" ' , e r f*aac1e 1 iii Tcahoa�t "D�te I�ut�a1 A hcatron I d plete <br /> {T+& "R t u mak" <br /> � A ��..�^ � � r i3� '�' <br /> PART 1: <br /> BASIC APPLICATION <br /> "See HELP"directs you to important additional information and assistance in Instructions,page 1. <br /> 1.APPLICANT CONTACT INFORMATION (See HELP 1): <br /> f� 1A.AUTHORIZED AGENT (See HELP 1A.) <br /> Name: <br /> Sexd o✓�1 2� (only if applicable; an agent is not required <br /> Complete mailing address: Name: <br /> 9 70 L4/%,y 24/' 48/ud £ Title: <br /> 141417 Z 4/1 4/h S'53 cj l Mailing address: <br /> Residential phone: ( 9s2) I/26— f 2£13 <br /> Residential phone: ( ) <br /> Business phone: ( ) <br /> Business phone: ( ) <br /> Fax (if available): ( ) Fax(if available): ( ) <br /> email (if available): email (if available): <br /> 2. PROJECT NAME OR TITLE(if applicable): I hereby authorize <br /> to act in my behalf as an agent in the processing of <br /> this application and to furnish,upon request, supple- <br /> mental nfo tion in support of this application. <br /> 3.NAME OR I.D.#OF WATER BODY/BODIES IMPACTED** <br /> i applicable; i known): Z r f—dY <br /> (f Pp fApplicant signature Date <br /> 4a.ANY WETLANDS IMPACTED?(circle one) IV NO 4c.If YES,indicate size of entire wetland(check one): <br /> 4b. If YES,what type(if known; circle all that apply): i Less than 10 acres(indicate size: 12 /14,12- ) <br /> � <br /> 0 10 to 40 acres <br /> 1 1L 2 (3J 4 5 6 7 8 R unknown 0 Greater than 40 acres <br /> 5. PROJECT LOCATION** (information can be found on property tax statement,property title or title insurance): <br /> 1/4 section:/-4,7<7 <br /> S L" Section: .?( Township: //g Range: 2$ <br /> County: /J/,7h Lot#: Block: Subdivision: <br /> 6.ADDITIONAL LOCATION DESCRIPTIONS** (f applicable; if known): Parcel ID#/Geocode: <br /> UTM coordinates: easterly northerly <br /> Project street address: Fire#: <br /> **For multiple water bodies or locations,attach additional sheets labeled ADDITIONAL WATER BODIES IMPACTED, <br /> ADDITIONAL PROJECT LOCATIONS, or ADDITIONAL LOCATION DESCRIPTIONS. <br /> 1 <br />