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APPLICATION FOR DEPARTMENT OP THE.ARMY PERMIT(33 CFR 325) OMB APPROVAL NO.0710-003 Expires Dec 31 2004
<br /> The pubhc burden for ttus collechon of mformahon�s esumated to average 10 hours per responsq although the majoriry of applications should require 5 hours or less. This includes
<br /> the time for reviewing inshvctions,searching existing data sources,gathenng and maintaining the data needed,and completing and reviewing the collection of infocmation. Send
<br /> comments rogarding this bwden estimate or any other aspect of tlus collection of infonnation,inciuding suggestions for reducing this burdeq to Department of Defense,W ashing[on
<br /> Headquarters Service Directorate of Information Operations and RepoRs,1215 Jefferson Davis Highway,Suite 1204,.qrlingtoq VA 22202-4302;and to the Office of Management
<br /> and Budget,Papecwork Reduction Project(0710-0003),Washington,DC 20503. Responden[s should be aware[hat nohvithstanding:ury other provision of law,no person shall be
<br /> subject to any penalq�for failing to compiy with a collection of infonnation if it does no[display a currendy valid OMB control number. Please DO NOT RETURN your form to
<br /> either of[hese addresses. Completed applications must be submi[[ed to the Dismct engineer havingjunsdiction over the location of the proposed activity.
<br /> PRIVACY ACT STATEMENT:Authorities:Rivers and Harbors Act,Section]0,33 USC 403;Clean Water Act,Section 404,33 USC 1344;Marine Protection,Research and
<br /> Sanetuaries Act,33 USC 1413,Section 103. Pnncipal puryose:[nfortnation provided on this fonn will be used in evalua[ing the applica[ion for a pennit. Routine uses:This
<br /> infonnation may be shared with the Departrnent of Justice and odier Federal,state,and local govemment agencies. Submission of requested information is voluntary;however,if
<br /> infortnation is_not provided,the peemit apn�ication cannot be evaluared nor can a oermit be issued
<br /> ITEMS 1 THROUGH 4 TO BE FILLED IN BY THE CORPS
<br /> 1,APPLICAT[ON NO. 2 FtELD OFFICE CODE 3.DATE RECEIVED 4.DATE APPLICATION COMPLETED
<br /> YOU DO NOT NEED TO COMPLETE ITEMS 6-10 and 12-25 in the SHADED AREAS.
<br /> All applicants must complete non-shaded items 5 and 26. If an agent is used,slso complete items 8 and 1 1. This optional Federal form is valid
<br /> for use onl when included as art of this entire state a lication acket.
<br /> 5.APPLICANT'S NAME 8.AUTHOR(ZED AGENT'S NAME AND TITLE(an agent is not required)
<br /> �I`�uh._ .)� hns�_n __..---- _�Ton1 �s��.y----�t�t1�f1��,.._�'o✓rt�G�� t'�d�r�_
<br /> b.APPLiCANT'S;4DT)RESS 9.AGENT'S,4DpRESS �0 �r{� (.,tt�g, �jJ'1G2. _ _
<br /> __ �----
<br /> 7 APPL;ICANi"S T'I#ONE NO. 1�.AGEN'f'S PHnN�NO. `
<br /> _ _ _ _----- ------._.—.---1-- ---- _ _ _ __-- _ — –�
<br /> 1l.STATEA4ENT OF AI�THORIZA'ftOn(�fappGcable:complete only rf au�horizing an agent) �
<br /> 1 hereby authorize to act on my behalf as my agent in the processing of this application and to furnish,upon request,
<br /> supplemental information in support of this permit application.
<br /> ��,4PPLiCANT"�ciC',A',�TUI�� �� '� • � r�� � —_ DATE: � ��Jr'.
<br /> ; 12.PRO7GCTNA?vtL'_QR.7'(7`LL:(see instructiotts}f _
<br /> t3:NAME Ok WA`f�RBCJDY,[F Kt�OWiV(if applic�ble) }4.PROJECTSTR�EET ADDR�SS�(rf applicable)
<br /> I l5.LOCATION OF PR01EC'T
<br /> � I6.dT}{E2 LDC;ATION DESCRIP'['tONS,tF KIvOWN(see instrucrions) _
<br /> � 37.DIR�C7'K}RS"I��'HE StTG l8.NATURE�3�'ACTtVITY � � � � �
<br /> �'� 19,PRO.IECT PURPOS��� � 20.REASON(S)�?OR DISCHA2GE �
<br /> � 27.TYPFS OF'MATGRIAL B��its DISCt{ARGED AND THE A?v1pC°N1'OF}3ACH:T`iP�IN CliB1C YARDS
<br /> � 22.�SURI'ACE A[;EA lN ACR�S OI WETl,ANDS OR��'['HER WA'T'ERS X'II.[..�1'J �� � � �
<br /> � �3 IS A��Y PORTION t7F�THE W�R�i AI.,RE>AD5'CQivIPE,ETE^�YES�� __ _____ 'JO___3F YES.DESCf�B6 C(JMPt;ETED WORK
<br /> ?4.ADDRESSES OF AI)JOINING PRpPERTY UV,'3�ERS.
<br /> 25 LIST OF OTS3CR CI.R'7'iFICA'i7flr\'S OR APPROVALS/DENL�L.S RLCCIilE„7 PRCiMOTIIEIi I�CDERAL.STAT�OR L(�AL AGENCIES FQR _
<br /> WORI�D�SCP.IBED�1 THIS APPLtGAT(ON. � � ��� � � � � �� �� � �
<br /> 26. Applieation is hereby made for a permit or permits tu��uthorv.c tlic ���:rl.Jc�,cr�bed in ihi;applic�uion. I certit}�that the inlurmation�n Uus
<br /> application is complete and accurate. I further ceRify that 1 possess the authority to undertake the work described herein or am acting as the duly
<br /> authorized agent of the applicant.
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<br /> '.,r ,fi�+'�i ,`b�'dP�Gf�'' " T�WCCI..' .. gnature of agent(if anY) e ,
<br /> The application mus be signed by the person who desires to undertake the proposed activiry(applicant),or it may l�e signed by a duly au[horized agent if
<br /> the statement in Block 1] 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,conceals,or covers up with any trick,scheme,or disguises a material fact or
<br /> makes any false,fictitious or fraudulent statements or representations or makes or uses any false wri[ing or document knowing same to contain any fal l�'�'���r
<br /> fictitious or fraudulent statements or entry,shall be fined not more than$10,000 or imprisoned not more than five years or both. ,� � � 3����
<br /> ENG FORM 4345,Jul 97 EDITION OF FEB 94 1S OBSOLETE. (Proponent:CECW-OR ` �r.�
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<br /> �4 i LURlt"� n'
<br /> Minnesota Local/State/Federal Application Forms for WatedWedand Projects �±+ ,.,,
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