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4 <br />^jrA <br />oiding <br />• ^ •izaucr^ <br />ORIGINAL DOCOMRMT <br />BL cOMMUWCATIONS.MEPJA_Diy!SION <br />• .L*I • <br />• ••t •• <br />•• • <br />•• U <br />INSTRUCnONS - PLEASE READ CAREFULLY <br />•• <br />A copy of this forni, with copies of all plans, drawings, etc... should be sent to each agency indicated below. Pleas; chec <br />the appropriate spaces below to show everywhere you are sending this form. Remember to keep a copy for your records. <br />ut • <br />y The LOCAL GOVERNMENTAL UNIT (LGU) city, county or waters management organization . <br />Y The local SOIL & WATER CONSERVATION DISTRICT ^ HENNEPIN SWCDQCARVER SWCC*‘ <br />y MINNESOTA DEPARTMENT OF NATURAL RESOURCES (MDNR) Regional Office <br />• ■■■■ — m » . • » . • • <br />Y US A.RMY CORPS OF ENGINEERS (ACOE) aL* Dept, of the Army, Corps of Engineers, St. Paul Distric <br />• • •• ATTN; CO-R, 190 Fifth Street East, St. Paul, MN 55I0I*ld3S <br />Note : The above agencies may provide a copy of your completed form to the Minnesota Pollution Control Agency <br />(MPCA). MPCA water quality issues may apply to your proposed project. <br />.... . . • .*•••*" <br />• • ' * * <br />ATTENTION (From USDA); Any activity including drainage, dredging, filling, leveling or other manipulations, <br />including maintenance, may affect a landuser ’s eligibility for USDA benefits under the 1985 Food Security Act as <br />amended. Check with year local USDA office to request and complete Form .AD-1026 prior to-initiating activity. <br />*IMPORTANT: Some agencies, including the Corps of Engineers a.nc ‘thc MDNR accept this ftfnh as a permll <br />application fo.rm..If you wish this form to constitute an application to me Cop*.s and/or MDNR for any necessary pe.-r <br />, T . I <br />for your proejets please carefully read the following information and sign whe.'c indicated.t •. « <br />77WVVVVWVV7VWVVVVWWVVVVV^VVVVVV.VVWVVWVWVWVV7V <br />*• M <br />Application is hereby made for a permit tO’authorize the activities desc.-ibed he.'cin. I ce.'ti.^.that.I axt» familiar with me. <br />infdrrriation coritained'in mfs application, arid that to the best of my knowledge and belief such information is true,* <br />complete and accurate. I further certify that I possess the authority to undertake the proposed activities or I am acting as <br />f • I * ■ <br />the duly authorized agent of the applicant. , . *■ <br />Signature of Applicant Date ’KIiWSTqn/ <br />^ * ••• • <br />, , • mm ^ <br />Date <br />Note- The application must be signed by the person who dcsi.'es to undertake the proposed activity (Appheant <br />or it may be'sighed by a d-jiy authorized agent if the informaticn requested below is provided <br />. . , *• ...... . • * <br />A,cm-5 Na/nc and Till: OUttM W/ 0/\i ^ A I A^Pf’U^64^^T~' <br />Agan.-sAddrass ^ So. 9.^'^ <br />Aga,.,', r=,adhcna ,Qa , ) - q9oo ' <br />• <br />1 3 U C Scciioit 1001 provides Uiii: V»“nocvcr, in any manner wichin ihc juris^!cticr. of any department or agency of the United Stales <br />Unowinoly and wilUuUy falsiOes. conceals, or covers up by ^y Inck. scheme, oc dcv-ce a material fact or makes any false, riciidous or • <br />liandukm statements or representations or makes or uses any false writing or documc.ni knowing same to contain any false, fictitious, or . ^ <br />iraudulciii siaicni’cni or entry, shall be fned not more than SIC.OOO or imprisoQ^d not morc*tiun fivjt.ycars. or both.