01-21-1997 Planning Packet - Laserfiche WebLink

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• • • ♦ .V •^4 t •« t« • • - H t « * i *• V- ** *. • • •. “ V. k . • • • • INSTRUCTIONS - PLEASE READ CAREFULLY A copy of this form, with copies of aJl plans, drawings, etc... should be sent to each agency indicated below. Plea ‘ the appropriate spaces below to show everywhere you arc sending this form. Remember to keep a copy for your LOCAL GOVERNMENTAL UNIT (LGU) city, county or waters management organization -X SOIL & WATER CONSERV ATION DISTRICT ^ HENNEPIN SWCDQCARVER SWCii' — MINNESOTA DEPARTMENT OF NATURAL RESOURCES (MDNR) Regional Office — US ARMY CORPS OF ENGINEERS (ACCE) at: DepL of the Army. Corps of Engineers. St. Paul District ATTN: CO-R, 190 Fifth Street East. St. Paul. MN 55101-163; N2tc: The above agencies may provide a copy of your completed form to the Minnesou Pollution Control Aeenev (MPCA). MPCA water quality issues may apply to your proposed project ^ ^ • * * * * . • • ATTENTIONIFrqm USPAL Any activity including drainage, dredging, filling, leveling or other manipulations includtng 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.^^I!ORTANT: Some agencies, including the Corps of Engineers and the MDNR accept this fo'rxfi as a permil’' ’ ' application form. If you wish this form to constitute an application to the Copts and/or MDNR for any necessary perr for your proejets please carefully read the following information and sign where indicated * ( t « •WWvWWVVWWVWWVWWVWVVWWVWVVWWVVWWWVVv • • . - I. ^ Application IS hereby made for a permit to-authorize the activities described herein I ceni^ that I ^ familiar with the information contained in this applicauon. and that to the best of my knowledge and belief such information is true • wmplete and accurate. I further certify that I possess '-he authority to undertake the proposed activities or I ani acting as inc duly authorized agent of the applicant. ’ . Signature of Applicant Date ’ i.., • • \i^jnj0[b Date Note The application must be signed by the person who desires to iJndertake the prooosed activity (Xpplicaht) or ,t may bfe'signed by a duly authorizcd.agent Vf the information’ 'requested below ,s provided' * Agem's Name and Title • • Agent's Address Agciii i Tetephone < ^ I*/- ) ^ fe. \A))^JgK3A/ ToQ APPU-d/WT-' DrUlo rCOS CSNligr? So. *' 8 U C Scciioii 1001 provides that: Whoever, in any manner within ihc jurisdiction of any dcparimeni or ajency of ihe t/niied Suios Vjrow.njiy a„j w.lUuUy falsifies, conceals, or covers up by any lock, scheme, or device a material fact or makes any false, licuilous or l•al.dllkm slatciiicnii or reprcsenialions or makes or uses any false wniing or documem knowing same to coniain any false, riciilioos. or IrigdulciU siaien'cnl or entry, shall be fined not more than J 10.000 dr imprisooed noi more'Uun fivi.ycars. or booi. V. a