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TH3 OBJECTIVES OF THE WORK for which a permit is sought are: <br />•J <br />' C c <br />2^ <br />THE FOLLOWING SUPPLDJT-TNTAflY DATA IS ATrACL^U): (Check epplicable sectic.is below.) <br />I [Sketch □ Topographic tr.ap CU Cros? Sect ions C,^3oundings C'J Letter <br />□ Plat OPlan <br />(□other (specify)__ <br />□ Prof [□Borir.g logs CI3 Air photo <br />The applicant declares that the information submitted'herewith and the statements made <br />herein are a true and correct representation of the facts, and that the filing of this <br />^application and information with the Commissioner of Conservation is prina facie evidence <br />.'of the correctness thereof. <br />t‘ * <br />.Dated ^hisl.25t^day of__July*_________19ArL; <br />«* $ <br />App 1 i cant _ ayn^O. Andrs_______ <br />^ V, • CPrlnt o- tjpe oanti <br />Signed . ^ <br />Shore Hills, Route 2 <br />Address Excelsior, Minnesota <br />»> <br />State of Minnesota <br />ofCounty of <br />S3. <br />AFFIDAVIT <br />I <br />I <br />On this day of zM A,D. 19 before me personally appeared <br />|who being first duly sworn and to me know.* to be the person_ _who executed the foregoing <br />application, acknowledge(s) that Vxa executed the same as own free act and deed and <br />that the statements, maps, plans, documents, and other supporting data are true and correct <br />accordi g to kw best knowledge and belief. X* \*‘*** **' <br />Notary Public_ _ _ _ _ _ <br />My commission expires ---------- <br />County <br />n,: ''i- 19 ___ <br />(Attach mPs, plans and other itens cheeked abcr.e.J <br />-c <br />« '