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ion <br />2 on <br />reduc <br />Dod <br />to re <br />D in- <br />/ ■ <br />r.: .. <br />r*- <br />' f <br />-V <br />r! <br />I <br />l,i • <br />TO?622-02 <br />Rev. 12/81 <br />f|||r department / otf <br />TiN)[?!flOEs<S)TrA <br />k natural resources <br />0^iJO MmFERMIT APPLICAnm <br />TO worn IX PROTECTEO WXTE] <br />(INCIUOING DAM <br />w^of 7 <br />6fFICE USE ONLYT <br />NO.y. <br />1 <br />► ►Please read instruclions before attimpllng to complete this applicali5ir^^QlO£0| <br />AppijMnfs Name (Las!, First. M.l.)I Authorized ^nt (if applicable) <br />□swco ac/c <br />DW.D.| pUSCOc <br />AOdre^ljfSrwi^J^, Box Number. City, State . Zip Code)nm. <br />Telephone Number&areacode <br />^/^)»75-S 71/m <br />Sections(s) <br />YJi <br />:T <br />Fire NO m Bw or.Inject Address.Coui y <br />II. PROPOSED PROJECT <br />□ fill ^^i^excavate <br />□ drain, <br />□ remove <br />□ abandon <br />□ install <br />□ construct <br />□ other (specify) <br />IV. ESTIMATED PROJECT COST <br />V. <br />VII. <br />BRIEF EXPLANATION OF PROJECT <br />III. PROJECT AREA <br />□ dam <br />Range(s) <br />tg-2-5 ■ <br />Projecl-will anecl Lake. Wetland or Watercourse <br />(nsrnPA niimhAP ^ A I <br />Lot, Block, Sub-Division <br />□ lake <br />□ wharf <br />□ bridge <br />□ harbor <br />□ riprap <br />□ channel <br />□ culvert <br />/tl^etland <br />□ shoreline <br />□ obstruction <br />□ watercourse <br />□ sand blanket <br />r~l norm^nAn# <br />□ shore-protection <br />□ other (specify) <br />JUSTIFICATION (Explain why this project is needed) ----------------------------------------------------- <br />/ioc/76fis^ m mmfj/jQ vmm^g^ lufiimpiL iimitff <br />• \ « <br />EXVtltOXXtEXTAL .mrw, t.^nticpated changes to the water and related land resources, tncludin, una^ibiTM detrimental eXects) <br />ALTERNATIVES (Other alternatives to the action proposed) <br />fOO ^c/^/e>/^ <br />a * 'a <br />f ,» <br />0 -• • • a»< •• • <br />• • •• •• • <br />•. <br />concerning this application are true and correct to th* imki m Tjk^formjtl^ubinttt^ and statements made <br />• * <br />conri.fninn .hie ,„-i7 ®’"*' 'mofmation^ ^ concerning this application are true and correct to the uest of jgyirnowled <br />^ ^ t Tc. A/: . <br />CTATC nc r____state of <br />COUNTY OF <br />tN\VwKJX»AL.OX AXr <br />VK Mr WM.t, <br />SiOMure of Owni thqUzed Dale J <br />2 <br />j^ribed and swdrn Jo beti/ie me this <br />- <br />StonalOre of Leasee , . .. <br />• • « w Date . <br />• ♦ • • • <br />• • • . ‘ <br />A <br />Distribution: <br />’ White: DNR <br />Blue: SWCD <br />Green: Watershed District <br />Goldenrod: City or County <br />Pink: Army Corps of Engineers i <br />Canary; Applicant !