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Miaacsota Wctlaad CoascrvatloB Act <br />appucahon for <br />CERTinCATE OF NO LOSS OR EXEMPTION* <br />APPUCANT AND PROJECT LOCATION INFORMATION <br />Tom Cullum LGU Minnehaha Creek Wat i District <br />Name(s) of Applicant <br />785 FoTidale Road <br />Project Location: 1/2 N I/4_ML S 36T118R23 <br />UTM Coordinates: X:________Y:_________ <br />Street Address <br />_____Orono. MN 55391 <br />County Kame/iNumber <br />20092 <br />City, State, Zip Code <br />Minor Watershed Name/Number:___ <br />Size of entire wetland: 0.3 acres <br />Wetland type: Circular 39 _____Type 5 : NWl PUBGx <br />L_).( <br />Telephorve (Day)_____(Everung) <br />Check one: ■ <S0Vo □ 50%-80% or □ > 80% <br />Check one: □ Agricultural land; ■ Non-ag. land <br />PROPOSED PROJECT DESCRIPTION <br />Describe the nature and purpose of the proposed pro|ect: See attached narrative <br />(«Mdi tdilitioiMi pigH iroHdtd) <br />Timetable: project will begin on 1/15/04 (mo/day/yr) and will be completed by 3/15/04 <br />The wetland actiyity at the above site qualifies for the following under the Wetland Conservation Act (WCA) (check one): <br />No Loss Detcrminatioa (attach plans) <br />EiemptiOB #(per MN Rule Chapter 8420.0122) (Note: Applicant is responsible/or submitting the proof <br />necessary to show qualification for the exemption claimed.) <br />DcscriptiOB of Exemption Claimed: <br />APPLICANT SIGNATURE <br />The information provided for this determination is truthful and accurate to the best of my knowledge. I ensure that, in draining oi <br />filling the subject wetland under ah exemption noted above, appnqmate erosion control measures wUI be taken to prevent <br />sedimentation of the water, the drain or fill will not block fish passage, and ^he drain or fill will be conducted in oonq>iiance with all <br />other applicable federal, state and local requirements, including best management practice and water resource protection <br />Its established under Minnesota Statutes, Chapter 103H. <br />(Signature of ^plicmit) <br />1;VIA. C)l(ilU/U /A/S fO'Z <br />(Date) ^ <br />0 5 m3 rj <br />C«ttiGilt ofHo^M or BMptioa (K)00) <br />Pliilori