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<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 /> 1A.AUTHORIZED AGENT (See HELP IA.)
<br /> Name: ife£61 6''11x) (only if applicable; an agent is not required)
<br /> Complete mailing address: Name:
<br /> 9 70 14/.-/7 24/ 8494, 't/ Title:
<br /> 'V4,7 Z al st rn ti S S 3 9 / Mailing address:
<br /> Residential phone: ( 9S2) N26" f 2 GV3
<br /> Residential phone: ( )
<br /> Business phone: ( )
<br /> Business phone: L_ )
<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 /> t'iis 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 l //' �� 7 .--... Z t f—m/
<br /> (f Pp f Applicant signature Date
<br /> 4a.ANY WETLANDS IMPACTED?(circle one) e, NO 4c.If YES,indicate size of entire wetland(check one):
<br /> 4b. If YES,what type(if known;circle all that apply): 4 Less than 10 acres(indicate size: 12 /1 ' )
<br /> O 10 to 40 acres
<br /> 1 IL 2 0 4 5 6 7 8 R unknown ©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: 3C Section: Township: //I Range: 2$
<br /> f
<br /> County: / 4,7 Lot#: Block: Subdivision:
<br /> 6.ADDITIONAL LOCATION DESCRIPTIONS** (if 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.
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