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Project Name and/or Number: 2018-127 <br />PART FOUR: Aquatic Resource Impact' Summary <br />If your proposed project involves a direct or indirect impact to an aquatic resource (wetland, lake, tributary, etc.) identify each <br />impact in the table below. Include all anticipated impacts, including those expected to be temporary. Attach an overhead view <br />map, aerial photo, and/or drawing showing all of the aquatic resources in the project area and the location(s) of the proposed <br />impacts. Label each aquatic resource on the map with a reference number or letter and identify the impacts in the following table. <br />Aquatic <br />Resource ID (as <br />noted on <br />overhead view) <br />Aquatic <br />Resource <br />Type <br />(wetland, lake, <br />tributary etc.) <br />Type of <br />Impact (fill, <br />excavate, <br />drain, or <br />remove <br />vegetation) <br />Duration of <br />Impact <br />Permanent (P) <br />or Temporary <br />(T)1 <br />Existing Plant <br />Overall Size of <br />Size of Community <br />Aquatic <br />Impactz Type(s) in <br />Resource a <br />Impact Area' <br />County, Major <br />Watershed #, <br />and Bank <br />Service Area # <br />of Impact <br />Areas <br />'If impacts are temporary; enter the duration of the impacts in days next to the "T". For example, a project with a temporary access fill that <br />would be removed after 220 days would be entered "T (220)'. <br />21mpacts 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 <br />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 <br />along the flowline of the stream followed by the area impact in parentheses). For example, a project that impacts 50 feet of a stream that is 6 <br />feet wide would be reported as 50 ft (300 square feet). <br />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". <br />4U se Wetland Plants and Plant Community Types of Minnesota and Wisconsin 3rd Ed. as modified in MN Rules 8420.0405 Subp. 2. <br />5Refer to Major Watershed and Bank Service Area maps in MN Rules 8420.0522 Subp. 7. <br />If any of the above identified impacts have already occurred, identify which impacts they are and the circumstances associated <br />with each: <br />PART FIVE: Applicant Signature <br />❑ Check here if you are requesting a pre -application consultation with the Corps and LGU based on the information you have <br />provided. Regulatory entities will not initiate a formal application review if this box is checked. <br />By signature below, I attest that the information in this application is complete and accurate. I further attest that I possess the <br />authority to undertake the work described herein. <br />Signature <br />Date: <br />I hereby authorize Wayne Jacobson to act on my behalf as my agent in the processing of this application and to furnish, upon <br />request, supplemental information in support of this application. <br />1 The term "impact" as used in this joint application form is a generic term used for <br />disclosure purposes to identify activities that may require approval from one or more <br />regulatory agencies. For purposes of this form it is not meant to indicate whether or not <br />those activities may require mitigation/replacement. <br />Minnesota Interagency Water Resource Application Form February 2014 Page 4 of 1 1 <br />