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<br /> NA•026620-03B (V2.02 for MS WORD)09/Ol/04
<br /> Minnesota Local/State/Federal A lication Form for Water/Wetland Projects
<br /> For Internal Use Only
<br /> Application No. Field Office Code Date Initial Application Received Date initial Application Deemed Complete
<br /> PART I: BASIC APPLICATION f �'��1d���::.�
<br /> "See HEI.P"diruts you to important additional information and assistance in Instructions,Page:. % ��` s %+,l
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<br /> I. LANDOWNER/APPLICANT CONTACT INFORMATIOv(See Help 1) '/ �` ���> � :;
<br /> Name:A�a�11 L.G2�G(/✓� Phone: 9SZ' S8S G 37 7 �c�i , -w� ���� ..�
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<br /> Complete mailing address: �5--35 ��nS !Ol/�f /eOaII� V�Qy�� M�S 5.39� �L�,� ��`r�.����� :h;�
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<br /> lA. AUTHORIZED AGENT See He! IA On! i a lrcnble;an n ent rs nol re uired .> w�
<br /> Name:M!/l�ef�t PO✓{a(ol�DYed,�rt(� Phone: �J Jr2-�"J'7'�YS� ��.+,����"��
<br /> Complete mailing address:5-QD WP,�1 Gu�(CC StY�e� �Ct/S'idV /�/1IV �.��/
<br /> 2. NAME,TYPE AND SIZE OF PUBLIC WATGRS or WETLANDS IMPACTED(Attach Addr[rona(Projec�Area sheets ifneeded)
<br /> Name or LD.t!of Waters Impacted(if app(icable;if known): �/lC ,Uinp���.te,,�...
<br /> (Check all that apply):�JLake ❑River ❑Wetland type� 1 ❑ 1 L ❑2 ❑3 ❑4 ❑5 ❑6 ❑7 ❑8
<br /> ;r,dic.^,te siz�of entire iak�or�i�eu.^,nd{check ore;: �j :.ess tnan ;G a,,,,,s;iodica2z�izc. } �;0.�'!C a..•es �!.:-e::!e_t!�z,;an,cr�c
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<br /> 3. PROJECT LOCATION (lnjorma(ion cnn be jound on property tac stalemen(,properly(itle or tille inst�ranceJ:
<br /> Project street address:/�,j5 Qd�INS 1pGi/tf�04C� Fire k: P��� '' Ciry(if applicable):
<br /> 'h Section: Section: Township#: Range#:OS��723��%,/ co��nry: �eh�tP�n
<br /> Y
<br /> Lot#: �jd l Block: DU / Subdivision: Watershed(name or#)
<br /> Attach a simple site locator map. If needed,include on the map written directions to the site from a known location or landmark,and
<br /> provide distances from known locations. Label the sheet SITE LOCATOR MAP.
<br /> 4. TYPE OF PROJECT: Describe the type of proposed work. Attach TYPE OF PROJECT sheet if'needed.
<br /> R�� - RaP �tPc�� See defails and d�au�rny af�rehed
<br /> 5. PROJECT PURPOSE,DESCRIPTION AND DIMENSIONS: Describe what you plan to do and why it is needed,how you plan to
<br /> construct the project with dimensions(length,width,depth),area of impact,and when you propose to construct the project. This is the
<br /> most important part of your application. See HELP 5 before completing this section;see What To Include on Plans(Instructions,
<br /> page 1). Attach PROJECT DESCRIPTION sheet.
<br /> Footprint of'projecr. .acres or square feet drained,filled or excavated.
<br /> y�o l,nca� �eef'
<br /> 6. PROJECT ALTERNATIVGS: What altematives to this proposed pro.ject have you considered thlt would avoid or minimize impacts
<br /> to wedands or waters? List at least TWO additional alternatives to your project in Section 5 that avoid wetlands(one of which may be"no
<br /> build"or"do nothing"),2nd explain why you chose to pursue the option described in this application over these alternatives. Attach
<br /> PROJECTAI.TER:'VAT/VES sheet if needed.
<br /> 7. ADJOINING PROPERTY OWNERS: For projects that impact more than 10,000 square feet of water or wetlands,list the complete
<br /> mai!ing addresscs of adiacent propem�awners on an attached.;enaratr.sh�ei. !Sre HF.i,P 7;
<br /> 8. PORT[ON OF WORK COMPLETGD: Is any portion of the work in weNand or water areas already completed? ❑Yes �No. If
<br /> yes,describe the completed work on a separate sheet of paper labeled WORK ALREADY COMPLCTED. (See HELP S)
<br /> 9. STATUS OF OTHER APPROVALS: List any other permits,reviews or approvals related to this proposed project Uiat are either pending or
<br /> have already bcen approvcd or denied on a separate attached sheet. See HELP 9.
<br /> (0. 1 am applying for state and local authorization to conduct the work described in this application. 1 am familiar with the information
<br /> contained in this application. To the best of my knowledge and belief,all information in I is true,com lete and accuratc. 1 possess
<br /> the authoriry ro undertake Ihe work described,or 1 am acting as the duly authoriz e f d n .
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<br /> Signalure ofapplicnnt(Lnndowner) Dnte Signnture ofagen!(i npp rcuble) Dn�e
<br /> This block must be signed by the person who desires to undertake the proposed acuvity and has the necessa.ry property rights to do so. If only the Agent has signed,
<br /> please attach a separate sheet sig�ed by the landowner,giv�ng necessary authorizatlon to the Agent.
<br /> Minnesota Local/State/Federal Application forms for WatedWetland Projects
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