02-24-1997 Council Packet - Laserfiche WebLink

Home Browse Search

• . •ft • •%* \» % < .k*I* •« • ••• • r # •M • Kt i • il • •• •• •- • • $. • • - fNSTRUCnONS - PLEASE READ CAREFULLY • • • • A copy of this form, with copies of all plans, drawings, etc... should be sent to each agency indicated below. Pleas' eh the appropriate spaces below to show everywhere you are sending this form. Remember to keep a copy for your r^ord^ The LOCAL GOVERNMENTAL UNIT (LGU) city, county or waters managemcat organization y The local SOIL & WATER CONSERVATION DISTRICT ^ HENNEPIN SWCDQCARVER SWcb' - y MINNESOTA DEPARTMENT OF NATURAL RESOURCES (MDNR) Regional Office — US ARMY CORPS OF ENGINEERS (ACOE) at: Dept, of the Army, Corps of Engineers, St. Paul District ATTN: CO-R, 190 Fifth Street East, St. Paul, MN 55101-1^38 Note: The above agencies may provide a copy of your completed form to the Minnesota Pollution Control Agency (MPCA). MPCA water quality issues may apply to your proposed project. attention (From USPA): Any activity including drainage, dredging, filling, leveling or other manipuiations, including maintenance, may affect a landuser’s eligibility for USDA benefits under the 1985 Food Security Act as* amended. Check with your local USDA office to request and complete Form AD-1026 prior to'initlating’activity. *’ IMPORTANT: Some agencies, including the Corps of Engineers and'the MDNR accept this fo'rrh as a permil application form. If you wish this form to constitute an application to the Copts and/or MDNR for any necessary pem for your proejets please carefully read the following information and sign where indicated. • I •• t * * • WVVVV7V7VW7WVVWVVVWVVVVVVVWVVV.VWWWWV7WVWW .• ... «. Application is hereby made for a permit lo authorize the activities described herein. I cetii.fy.lthat l ^ familiar with the. information contained in this application, and that to the best of my knowledge and belief such information is true, • complete and accurate. I further certify that I possess the authority to undertake the proposed activities or I ani acting as the duly authorized agent of the applicant. Signature of Applicant Dale • k- M • • I « • UJ)W$ToNy Date 11 I# Note. The .ipplication must be signed by the person who desires to undertake the proposed activity (Xpplicaht) or It may b<:‘sighed by a duly authorized agent if the information requested below is provided ' ' • I Agent■? Najitc a/id Title tX- Agent's Address Ur*^l0 rep's C£.Nlig<7 ATroy?^tey Agent s Teleplione ( ^ |n\K) l8 U S C Section 1001 provides that: Whoeve/, in any manner wiihin ihc jurisdiction of any department or agency of the fc/nited Suios ijiowmgly and willtully falsines, conceals, or covers up by ^y Irick, scheme, or device a material fact or makes any false, fictitious or • h ludulem statements or representations or makes or uses any false writing or document knowing same to contain any false, fictitious, or . Iraudulciit staicnicni or entry, shall be fined not more than SIO‘000 dr rmprisooe^ not morc'ihin Hvi.y^s. or both.