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� � � � � <br /> � �� � � � � � � � / � � o � f � � I <br /> 1. Project/Site Information <br /> ProjectlSite Name: 3382 Bayside Road Local Government Un t: MCWD <br /> Location (address and/or T, R, Sec.): Same as site name <br /> 2. Applicant Information <br /> Applicant Name: Mike Huthwaite Address: 7155 Ainsworth Drive <br /> City> State, zip: Germantown, TN, 38138 <br /> E-maif: mhuthwaite@buckman.com Phone: (901} 351-7741 <br /> 3. Agent/Consultant Information <br /> Company Name (if applicable): SER �ontact Person: Brian Burgner <br /> Address: 25580 Nelsine Drive City, State, Zip: Shorewood MN, 55331 <br /> E-mail: brianb@gpsinnovations.com Phone: g52-471-1100 <br /> 4. Description of Request <br /> Check all that apply: pp Wetland Boundary (must atiach wetland delineation report} <br /> ❑x Wetland Type (Eggers & Reed and/or Circular 39 type) <br /> 5. Signature <br /> By signature below, lhe applicant requests a determination from ihe Local Government Unit under <br /> Minnesota Rules 8420.0225 on the submitted wetlanc� boundary and Eype information in this application. <br /> The applicant also affirms t at�t y are the owner of the subject property or have permission from the <br /> lan�wne to pursu is eter �nation. <br /> ; ` <br /> _.- -- ��' - /C� <br /> A icant or thoriz d Agent ign ure Date <br /> lmportant Notes: <br /> • 7he applicant may be required to submit multipfe copies of the reporUinformation to the <br /> LGU. The LGU may require the applicant to submit copies direct(y to Technical Evaluation <br /> Panel Members. Check with your LGU regarding their submittal requirernents. <br /> • The LGU decision must be made in compliance with Minnesota Statutes, section 15.99. <br /> For LGU use only <br /> Date Received: <br /> Page 1 of 1 <br /> BWSR Wetland Boundary/Type Application Form 11l10/08 <br />