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NA-02622.02
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<br />wlv. 12/81 PERMIT APPLICATION PAIR -'JelFPSE ONLY
<br />A ND
<br />DEPARTMENT OF TO WORK IN PROTECTED WATERS OR WETLANDS P
<br />NATURAL RESOURCES 0swco ElC/C
<br />`' 10WO C_IV
<br />► Please read instructions before attempting to complete this application.
<br />Applicant's Name (Last, First, M.I.)
<br />Authorized Agent (I1 applicable)
<br />Telephone Number&areacods
<br />Address (Street, RFD, Box N;:,rber, City, State, Zip Code)
<br />�>
<br />Government Lot(s) trailer Sectign(�)
<br />Sections(s)
<br />Township(s)
<br />Range(s)
<br />Lot, Block, Sub -Di isi
<br />NO rt h
<br />; l
<br />117
<br />?_ 3
<br />Y<<c ts�=CYF°!',•� e
<br />Fire No., Box No. or Project Address
<br />County .1
<br />Project will affect Lake, Wetland or Watercourse
<br />(name A rxmtbef. /.
<br />f known, Zak, -
<br />If. PROPOSED PROJECT
<br />III. PROJECT AREA
<br />❑ fill X excavate
<br />❑ dam ❑ culvert
<br />❑ drain ❑ construct
<br />❑ lake ❑ wetland p�bpter'(speci ' 1
<br />❑ remove ❑ other (specify)
<br />❑ wharf ❑ shoreline
<br />❑ abandon
<br />❑ bridge ❑ obstruction V-
<br />❑ install
<br />❑ harbor ❑ watercourse t
<br />❑ riprap Ci sand blanket
<br />❑ channel ❑ perrnanent dock
<br />X. ESTIMATED PROJECT CKT
<br />5
<br />OW EXKWTION OF nloJECT
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<br />JUSTIFICATION (Explain why this project is needed) %c /", �"► a'• �` ,• ! !,+ was ll•rj it t o • Ae;C <
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<br />fire-rnP ,.je Ifa1 Iin0 prevw.�t tlt,r C,t/itv l,tc. sir Aright �f n ,.t.. /.vt(
<br />ENVIIIA NNIEKTAL IMPACT (Anticipated changes to the water and r@/lated land resources, including unavoidable but detrimental effects)
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<br />Ir.iLJtin9 /C�f.v',t n✓ram tifv3 /'1"�✓�•"t/A9 /a/;t'L�:.,n(a.r.��r;ri/iI.). 1c•�c7 r�/'•=r_S,t/
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<br />ALTERNATIVES (Other alternatives to the action proposed)
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<br />I hereby make appbrcahon pursuRM to MnwsoU Statutes ChapM 105 12 and all supporting rules tar a permit to wart in of eTlect the aflr)ve named protected
<br />waters! in accordance wrtti all supporting mar» plem, and other mtormatfon submitted wrN this VOdcatron The ,rmmatron su0irint1 d artd statements made
<br />0onctrnrng errs appl-atwn we true and correct to Cie best of my knowledge
<br />4
<br />STATE OF 1. - ' YLM 0,
<br />COl1NTy OF C Pr'_ _fL trA-^.j
<br />Subsorbed and swan to before fm Oft
<br />W commris,on tip,ret r
<br />Signature or Notary )_A
<br />L_ � r'/ ��t1lt�>ti
<br />Srgrsalufe of Owns a Autrtaued Agent OaM
<br />nature Of Leases Date
<br />Distribution
<br />White
<br />ONH
<br />Blue
<br />SWCD
<br />Green
<br />Watershed D,strict
<br />Goldenrod
<br />City or County
<br />Pink:
<br />Army Corps of Engineers
<br />Canary
<br />Applicant
<br />1{,
<br />r ft .
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<br />
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