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91? u // <br />V. <br />N. <br />NI. <br />M. <br />IL <br />W IM RAW A►MMTM "r FW A <br />FFICE USE ONLY. <br />DEPARTMENT OF TO WM M MTMU WATT M <br />QSWCD Q <br />MMS(Mlr. o.. (Ritxww w wlEnri <br />NATURAL RESOURCES <br />► ► Phase read instructions bfrlore attempting to complete this application. <br />O w O O LMM <br />Applicant's Name (Last, First, M.I.) Authorized Agent (it applicable) Telephone Number aama code <br />Address {Box -Number, City, State, Zip Code <br />�53 .-� NA/ /Ji 4Grl/.) UA�t-, W IV4 57.5 Selj <br />Government LoXs) Quarter Section(s) Sectlons(s) Townships) Range(s) Lot. Block, Sub -Division <br />` f� / � % A /� cu � � /1 7 L L'rL/� <br />Fire No., Box No. or Project Address CountyProject will affect Lake, Vrletland or Watercourse <br />ktgwn tuber . _ IJ <br />M. PPIOPOSED PPAX ECT 111. PROJECT AREA <br />❑ fill pKexcavate <br />❑ dam G' culvert ❑ shore -protection <br />❑ drain Ffconstruct <br />Ji lake ❑ wetiand ❑ other (specity) <br />❑ remove ❑ other (specify) <br />O wharf Xshofeline <br />❑ abandon <br />❑ bridge ❑ obstruction <br />❑ inmil <br />❑ harbor U watercourse <br />❑ riprap ❑ sand blanket <br />❑ channel ❑ permanent dock <br />M. MTVTM AST MU <br />_ <br />MO E VMTIIM IF PM IMI f F'�qt! U E /I igW<tft/� Ir► T/`! y Cv yil �r� S i'F>r� <br />F,. // /, A Ay( st /� . ! A �/ liur✓ /� it aE /i <br />. <br />/VbL/F y FX a' r/A, r I c .•1 C l ti i, ins, r_! <br />AUMTIM (Explain wiry this project is needed) <br />JV t*0(//Z-E /`i/. r�1( /! / E Nfl ✓/C��� i it r./ii � LFI�IN f) % 7CT E �f/•l ii �L <br />�lV�A.rInKrE �/✓�� Lr-IC,c>a/ii� �--� <br />E► TRi WWT (Anticipated charges to the water and related land resources, including unavoidable but detrimental effects) <br />AW Lac frb41AII, J FU/� S W/ I / Lek <br />Pf11C1�� 1HFk't W/I/ +bSE A _`NSA T Tf /A <br />a: ( V <br />N,MI1111111111101 (Other alternatives to the action proposed) <br />i ^KM' mwt M WWMM pursuant to M1 --ro RAMON ChWW 105 42 and MI supporting rules for a lor" Mo work in or atMct Ma above ranad pro�yad <br />craws) M WXordanos wo aN supporting naps. plan, and olher mforrrMM submMMed wdh tun spplkaNO The IMM0001 lublrafNd and st7Aa 0 is Riede <br />cwwlrrmV Wit apWlkahon are Yue and Carer:t'D ft bad of " knowWr <br />c <br />STATE OF f ,1 _. L i C'r <br />COUNTY OF Sgnsture of <br />Subsr.; Owt and swan to bdore tics N <br />_ II _day of _ 19 <br />fw ao Waft a NOW <br />U <br />DIN <br />Distribution <br />White <br />DNR <br />Blue <br />SWICD <br />Gran <br />Watershed D*M <br />GofOer>foci <br />City or county <br />Pink <br />Army Corps of EngRmn <br />Canary <br />A X*carrt <br />