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• » t Sew <br />Rev 12 B5 <br />lA ^DEPARTMENT OE <br />:r »: .V rc/^‘;r/*\ <br />^ NATURAL RESOURCES <br />PfiniHr ;.rVtiCATION <br />TO WORK IN niu-i:f;.: r if;.uERS or wetiahds <br />,i5d r:..: owi cafetyi <br />► ►Please read instructions before attempting to complete Ibis a.'. i.cstion. <br />tiFHCF USE ONLY. <br />P A NO y <br />I" ■/ <br />nsWCD nc/c <br />□wo UUSCOE <br />I. <br />r- <br />Autbcnzcv: .'^nt (if applicable)Telephone Number 4 arpnccxie <br />Address (Street. HFO. Box Number. City. State. Zip Code> <br />4,//rZ-Alit'Afirlfhf\/-t:L/l Ajt'J .1 726:__ '* _______< <br />LOCATION OF PROPOSED PROJECT (BESURE TOii iCLUDE SKETCH SHOWING HOW TOGET TO THE SITE) <br />rr^—:--------r":—rr~.------n; r— _____' r,j.'Tr •\;rr~rrr~~r“rT:T—ir. .1- rm—r,,...—^Government Lot(s)Quarter Section(s) <br />V.'rv < <br />SectijinCiS) No Townshi^(s) No <br />rffg ,^7V /.;/ /<b <br />QQuqi’, ... , <br />1 jf . .> •’ f rr / / / / <br />Range(s) No <br />C ‘ -> <br />Lot. Block. Subdivision <br />w • / j, / I KX; <br />Hioioct wiiiaii'jci □ Lak(‘. DWcliandor □ Watercourse <br />.namoA numb<?r / // , ' / /; .* i ,;• y /*,/>• <br />if knr.wvni - / w <br />III.TYPE OF WORK PROPOSED (CHECK ONE)IV. TYPE Cr PROJECT (CHECK ONE) <br />^ excavate <br />□ fill <br />□ drain <br />□ construct <br />□ Install <br />□ repair <br />□ remove <br />n abandon <br />□ other (specify) <br />□ shoreline <br />□ channel <br />□ sand blanket <br />□ riprap <br />□ shore-protection <br />□ harbor <br />□ permanent dock <br />n wharf <br />^ obstruction <br />□ bridge <br />□ culvert <br />□ dam <br />□ other <br />(specify) <br />ESTIMATED PROJECT COST $VI. LENGTH OF SHORELINE AFFECTED (IN FEET): bytO <br />VII. <br />VIII. <br />VOLUME OF MATERIAL FILLED OR EXCAVATED (IN CUBIC YARDS) <br />/ <br />BRIEF EXPLANATION OF PROJECT: (EXPLAIN WH^ PROJECT CONSISTS OF AND HOW WORK WILL BE DONE) <br />/-I / A<X' ''.(.Z./C V/l-Oi^S t.< 7 <- (/'_ L t ^ /hrlftf'lifi <br />^/6TU<C»- r-c>/ \ (IIF. Cy/<£. r„> J <A (r\ if'^ ^A: l)\ <br />/\T 11!'t\C i t/tfC . <br />PURPOSE OF PROJECT: (Explain ^ this project is needed) <br />fh\i‘^r,\jfL M ^ yTr<r/r'CS f'oi— ‘ • t x , 7 / <br />< < i-H Ci' ^/\*-tLfhy <br />XII. <br />ENVIRONMEHTAL IMPACT (Anticipated changes to the vrater and related land resources, including unavoidable but detrimental eflects) <br />T iF#-/-V TU.\ c/(T /'// r'/\( y <"7 ■ \ <br />ALTERNATIVES (Other alternatives to the action proposed) f <br />A A « ^ m. . ^ m. . ^ A Ift. A l __________________________A A _ _ <br />watcf(s) in accordance witfi alt supporting maps, plans, and other information suOrr'itted w.th this application The inferand yj <br />concerning this application arc true and correct to the best of my knowledge ^ jCSi Vi <br />tements made <br />STATE OF <br />COUNTY OF <br />p)/V <br />// <br />Signature oj Owner or Authorized Agentd4 f J <br />Sinruv.ufc i Leasee <br />Subscribed and sworn to before me this <br />«, .1 ' ■■ <br />V ^ 4 i. <br />k <br />'Jjle <br />Date <br />Distnbiilion <br />My commission expires A// <br />White ONB <br />Blue: SWCD <br />Green Watershed District <br />Gold •nnxi City or County <br />Pink Army Corps of Engineers <br />Canary Apolicant