04-14-1997 Council Packet - Laserfiche WebLink

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» •• • V * .k*• « *1 • m ^ • M »* t •• • •* » j • «t« • « »• « iU • •• M t« • • • f r •» I • *. V- • • .. •• • rNSTRUCnONS - PLEASE READ CAREFULLY A copy of this form, with copies of all plans, drawings, etc... should be sent to each agency indicated below. Please eh the appropriate spaces below to show everywhere you aie sending this form. Remember to keep a copy for your record v/ • *Thc LOCAL GOVERNMENTAL UNIT (LGU) city, county or waters management organization y The local SOIL & WATER CONSERVATION DISTRICT ^ HENNEPIN SWCDQCARVER SWctJ* X MINNESOTA DEPARTMENT OF NATURAL RESOURCES (MDNR) Regional Office • .M • • •• kW*. • — US ARMY CORPS OF ENGINEERS (a COE) at: Dept of the Army, Corps of Engineers, St. Paul District ATTN: CO-R, 190 FiRh Street East, St. Paul, MN 55I0l-Id3 Note: The above agencies may provide a copy of your completed form to the Mirmesota Pollution Control Agency (MPCA). MPCA water quality issues may apply to your proposed project. • • • ^TTENTION.(From USpA): Any acuvity including drainage, dredging, filling, leveling or other manipulations, 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'initiating'activity. • • • I f.M^ORTANT: Some agencies, including (he Corps of Engineer's and*the MDNR accept this fo'rrft as a permir* ‘ ‘ application form, [f you wish this form to constitute an application to the Copts and/or-MDNR for any necessary pern for your proejets please carefully read the following information and sign where indicated. I • • • • •wwwvwwwvwwvvwvwwwvvwwv.www7vwvwwvW Application is hereby made for a permit to authorize the activities described herein. I ccrti,^.ilhat.( am familiar with the. information contained in this application, and Lhat 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 am acting as the duly authorized agent of the applicant. • • •• • Signature of Applicant Date r* • ••• « ••••* • • • WlWSToNy Note, The application must be signed by the person who desires to undertake the proposed activity (Xpplicant) or |( may be’sigtied by a duly authorized agent if the information requested “below is f ividcd’ ‘ Date •• k j • • Agent's Name and Title:--3oftN) fe. J ATror?tfey -Fog A-Pa\-64KT- 4^X0 -£.0S C£.(mo 'go "k,. 9+*' • I ^ • •• • Agent's Address ________'^0*S So. . Agent s Telephone ( ^ )^ ) — ^*5^00 PA) ^ . . • l8U.se Sccnon 1001 provides that: Whoeve/. in any manner within the jurisdiction Oi'any department or ajer.iy of the Uniied Suios tnowingly and willtully falsifies. Conceals, or covers up by wy Iriclc. scheme, or device a material fs^i or makes any false, tlcl'nious or *• fiaudulem siaiemenls or rcpresemalions or makes or uses any false writing or doc.c.ic. i k/ owing same to contain any false, riciitious. or . IrauduK iii siaicoKiU or cniry shall be fined noi more than SlCiCXX) dr imprisoofd not more ihin ri\i..y<Urs, or bolh.