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NA-026620-03B (V2.02 for MS WORD)09/O1/04 <br /> Minnesota Local/State/Federal A lication Form for Water/Wetland Pro'ects <br /> For Internal Use Only <br /> A lication No. Field Office Code Date Initiai A lication Received Date initial A lication Deemed Com lete <br /> PART I: BASIC APPLICATION <br /> "See HELP"directs you to important additional information and assistance in Instructions,Pnge l. .�.•:''�=';"p�e,n� <br /> Y '� .a�.��t`��� <br /> 1. LANDOWNER/APPLICANT CONTACT 1NFORMATION(See Help 1) �� <br /> Name: �0{'j ,,1 Dhh�S S� Phone: C�Jj�!�Z—�v�U b �'�': '8'c���a� `...s <br /> Comp]ete mailing address: ,:a.t ��"'" � <br /> /2?l� �Y'c�C�4'tf��r/tt' �c� (/11�iy2uf�l /1q/�f S�3`� � �� ���iE?k"a� � <br /> IA. A[iTHOWZED AGENT(See Help IA) (Only if applicable;an agent is not required) '" ��f��� <br /> Q /�,` `� �� <br /> Name:�iRhe�il� fU6�'CTi��- Ic.�►�/uj Phone: �JS2��7�`yT�y ,� ��\' <br /> Complete mailing address:- � � � �y�. <br /> �"d� GUe,�r-Cu,�e.�t-- ,Ex�el:s>vv� /19� S�3 3/ �Z�I�t£,���'' <br /> 2. NAME,TYPE AND SIZE OF PUBLIC WATERS or WETLANDS[MPACTED(Attach Additional Project Area sheets if needed) <br /> Name orI.D.#of Waters Impacted(ifapplicable;ifknown): <br /> (Check all that apply): �Lake ❑River ❑Wetland type� 1 ❑ I L ❑2 ❑3 ❑4 ❑5 ❑6 ❑7 ❑8 <br /> Indicate size of entire iake or wetland(check one j: ❑ Less tha�i 10 acres(indicate size: ) ❑IO to 4G acres �Grea;er than 40 acres <br /> /��rI�7C 1 Ur�.7 <br /> 3. PROJECT LOCATION (Information can be found on properry taz slatement,property title or title insurance): <br /> Project street address: �Z�� �,'WGll�/f;{Pp„q� �� Fire#: P���"" Ciry(if applicable): U/'�{?Z} <br /> r�-ll7--Z3 3Z-a�t9 <br /> '/<Section: Section: Township#: Range#: Counry: f�eyh���,.� <br /> Lot#: Block: Subdivision: Watershed(name or#)MG�p UTM location:N E <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 S/TE LOCATOR.�l/AP. <br /> 4. TYPE OF PROTECT: Describe the type of proposed work. Attach TYPE OF PROJECT sheet if'needed. <br /> SC'e �'�C�9�� <br /> 5. PROJECT PLIRPOSE,DESCRIPTION AND DIMENSIONS: Describe what you plan to do and why it is needed,how you plan to <br /> construct the project ti�ith dimensions(length,width,depth),area of impact,and when you propose to construct the project. This is the <br /> most importani 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 /> S�� A f�c�,�� <br /> Footprint of project: acres or square feet drained,filled or excavated. <br /> G. PROJECT ALTERNATIVES: What alternatives to this proposed project have you considered that would avoid or minimize impacts <br /> to wetlands or waters? List at least TWO additiona]alternatives to your pro,ject in Section 5 that avoid wetlands(one of which may be"no <br /> build"or"do nothing"),and explain why you chose to pursue the option described in this application over these alternatives. Attach <br /> PROJECTAL7ER�'ATIVESsheet ifneeded. <br /> Sc�e f�'�l—�'ehGc� <br /> 7. ADJOINING PROPERTY OWNERS: For projects that impact more than ]0.000 square feet of water or wetlands,list the r.omnlete <br /> mailing addresses of adjacent property owners on an attached separate sheet. (See HELP 7) <br /> 8. PORTION OF WORK COMPLETED: Is any portion of the work in wetland or water areas already completed? ❑Yes [�No. If <br /> yes,describe the completed work on a separate sheet of paper labe(ed WORK ALREADY CO'.bIPLF,TED. (See HELP 8) <br /> 9. STATUS OF OTHER APPROVALS: List any other permits,reviews or approvals related to this proposed project that are either pending or <br /> have already bcen approved or denied on a separate attached sheet. See HELP 9. <br /> 10. I am applying for state and local authorization to conduct the work described in this application. I am familiar with the information <br /> contained in this application. To the best of my knowledge and belief,all information in Part I is true,complete,and accurate. I possess <br /> tl�e authority to undertake the work described,or 1 am acting as the duly author' .gent o the applicant. <br /> 1 s <br /> ��, � � � � ����� <br /> ' - �.�,. -._-- r, �, �� ;: <br /> Si�halur+e of opplic �Lqndnwner)� :��t��� ,.," ignature of agent(if a�ZPlrcab[e) Date ' <br /> This block must be signed by the person who desires to undertake the proposed activity and has the necessary property rights to do so. ]f only the Agent has signed, <br /> please attach a separate sheet signed by the landowner,giving necessary authorization to the Agent. <br /> Minnesota Local/State/Federal Application Forms for Water/Wetland Projects <br /> Page( <br />