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APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT(33 CFR 325) OMB APPROVAL NO.0710-003 Expires Dec 31,2004
<br /> The public b�rden for this collecfion of informaeon is estimated to average IO hours per responsq although�he majonty of applications shoidd require 5 hours or less. This includes
<br /> the time for reviewing instrtwtions,seuching existing data sources,gathering and maintaining the data needed,and compkting and reviewing Ihe collection of information. Send
<br /> comments regazding this bwden estimate or any other aspect of[his collection of'infortnation,including suggestions for reducing this burdeq ro Department of Defense,Washington
<br /> Headquarters Service Directorate of Infom+ation Opera�ions and Reports,1215 Jcfferson Davis Highway,Suite 1204,Arlington,VA 2220b4302;and to the Office of Management
<br /> and Budget,Paperworic Reduction Roject(0710-0003),Wxshingtoq DC 20503. Respondents should be awaro that notwithstanding any other provision of Inw,no person shall be
<br /> subjcet ro aIry penalry for failing to comply with a collection of infonnetion if i�does not display a currently valid OMB conn-ol mm�ber. Please DO NOT RETURN your Corm to
<br /> either of these addresses. Completed applications must be submitted ro the Distnet engineer havingjurisdic�ion over the locazion of the proposed activity.
<br /> PRIVACY ACT STATEMENT:Authonties:Rivers and Harbors Act,Section 10,33 USC 403;Clean Water Act,Section 404,33 USC 1344;Marine Protection,Research and
<br /> Sanetuanes Act,33 USC 1413,Section 103. Principal purpose:(nfortnation provided on this form will be used in evaluating Ihe applicetion for n permit Routine uses:This
<br /> infomiation may bc shued with the Depamnent oFJustice and other Federal,state,and local govemment agencies. Submission of requated infortnetion is voluntary;however,if
<br /> information is not provided,the oermit application cxnnot be evaluaced nor cnn x pennit be issued.
<br /> ITEMS 1 THROUGH 4 TO BE FILLED IN BY THE CORPS
<br /> f APPL[CATION NO. 2.FIELD OFFICE CODE 3.DATE RECEiVFD 4 DATE APPLICATION CO!vtPLETED
<br /> YOU DO NOT NEED TO COMPLETE ITEMS 6-10 and 12-25 in the SHADED AREAS.
<br /> AU applicants must complete non-shaded items 5 and 26. [f an agent is used,also complete items 8 and 1 1. This optional Federal form is valid
<br /> for use only when included as art of this entire state a lication acket.
<br /> �.APPLICANT'S NAME 8.AUTlIOR17.ED AGENT'S NAMB AND TITLL-(ar,agent is not ru,uired)
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<br /> 6 APPL�ANT"S r�3D1�Sb,-' � 9.ACzL�vI`S ADDRCSS
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<br /> 1 L STAT�:NE�T OI�AliTHORIZA�f IU��rJ applicable,complete only rf a�uhonnng mt agen�J
<br /> 1 hereby authori����fp/!kq�yJ1�I,{S Djv��j� to act on my behalf as my agent in the processing of[his application and to tLmish,upon request,
<br /> supplemental in ormation in support of this per it application
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<br /> 2�:T„T�T'+7L`}�?TI-IE}��{��RTIFTCAT3<)'��QR APP1201'P;l S/D�irI?,��RECLN�D,R�7ivi Q'[1�C1�:FCD��2Ali,STATE UTt.C.00r1L ACZE2lC,�S FOR '�'-
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<br /> 26. Application is hereby made for a permit or permits to authorize thc���,r��se��i;ucu,�.,,��.,„p��r�4uo;�. i�eruiy :.,,:��.�nc„uonr.��i,�o�;;;n�;
<br /> application is complete and accurate. I further certify that I possess the authority to undertake the work described herein or am acting as the duly
<br /> authorized agentofthe applicant.
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<br /> Signa apphcant Date i�nature o agent ' Date
<br /> The application must be signed by the person who desires to undertake the proposed activity(appiicant),or it may be signed by a duly authorized agent if
<br /> the statement in Block I l has been filled out and signed. 18 U.S.C.Section 1001 provides that:Whoever,in any manner within the jurisdiction of any
<br /> department or agency of the United States knowingly and willfully falsifies,conceais,or covers up with any vick,scheme,or disguises a material f�(„gr„t
<br /> makes any false,fictitious or fraudulent statements or representations or makes or uses any false writing or document knowing same to cont�rc'eny f�sp;�"le.
<br /> fictitious or fraudulent statements or entry,shall be tined not more than$10,000 or impnsoned not morc than five years or both. r ��' `C'j
<br /> ENG FORM 4345,Jul 97 EDITION OF FEB 94 iS OBSOLETE. (Proponent:CE�'�{T�aR) ,�� �`'�,.
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<br /> Minnesota I.ocal/State/Federal Application Forms for WaterlV✓edand Projects y ` �:i_� 5 � -t�
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