DNR/boardwalk info - Laserfiche WebLink

Home Browse Search

ENSTRUCTIONS--PLEASE READ i;AREFULLY A copy of this fonn, �.vith copies of ail plans, drawings, etc., should be sent to each agency indicated below. Flease check the appropriate spaces below to shov✓ everywhere you are sending this form. Remember to keep a copy for your records. ,x LOCAL GOVERNMFNT UNIT (LGUI' Gty, county, or watershed management organization. � � Specify the LGU to which you are sending the form:_ C' ;�-�� "tl��,��^, �—� �� The IOC21 SOIL AND WATER CONS RVATION DISTRICT �SWCD) tor the pro�ect. Specify the county SWCD:_ ��,f�r+_t 1��_Ct_.___ � � WArFRsfiE� DisTRicr (if one ex�sts for the project areal. � Spr.cify the Watershed District:_/V� {_4v1V�1'�I��A- __ _ / .�i /� MINNESOTA DEPARTMENT OF NATURAL RESOURCES (MDNR1 regional office � U.S. Aknnv CoRr�s oF ENciNEERs(CORPS). Send the CORPS copy to: Department of the Army, Corps of Engineers, St. Paul District, ATTN: CO-R, 1 90 Fifth Street East, St. Paul, MN 55101-1 638 �_�ote: The above agencies may provide a copy of your compieted form to the Minnesota Pollutior Convol Agency iMPCA). MPCA water quality rules may apply to your proposed project. A1 fENTION FHonn iJSDAt: Any activity including drainage, dredging, filling, leveling or other manipulations, including n�aintenance, may affect a landuser's eligibility for USDA benefits under the 1985 Food Security Act as amended. Check with y��ur loc:�l USDA office to request and complete Form AD-1026 prior to initiatiny activity. IMPORl ANT: Some agencies, including the Corps of Fngineers and the MDNR accept this form as a perrriit application form. It ___ _ __ _- - yuu �°✓:sh tn�s form to constitute an application to the Corps and/or MDNR for any necessary permits for your pro�ect please c�irei�illy read the foliowinfl intonnation and sign where indicated. %%Y%%%Y%Yg%%YY%%Y%Y%%:YY%%%YY%1%%YI%YY%ZY%%%YY%%%Y%YY%%YYY%%YR%% Applicat�on is�hereby made for a permit or pennits to authonze the acUvities described herein. I certify that I am tamiliar with t!:e intorma on contained in this application, and that to the best of my knowledge and belief such information is true, �cxnplet ;' nd accurate. 'I further certify that I possess the authority to undertake the proposed activi��es or I am acting a� the duly�orized ag the applicant. �--��i 7 ��--� --.-- ��5 '� / �`4 -� -- - Siyriature of Applicant Date Signature of Agent Jate �Jote: The application must be signed by the person who desires to undertake the proposed activity (applicant) or it may be signed by a duly authorized agent if the information requested below is provided. �?c�<>,it�s f��arr�e an� title: ' . Agent's address: Ayent'� telephone: ( ► 1 8 U.S.C. Sec?i��n 1001 provides thar. Whoever, in any manner within the jurisdiction of any department or agency of The United States knuwinyly and willtully falsifies, concea!s, c;r covers up by any trick, scheme, or devir_e a material fact or makes any false, fictitious or fra;udulent statements or representations or makes or uses any false writing or document knowing same to contain any fa�se, fictitious, or tr,u�iul��nt �i;�rr,mrnt ��r entry, shall be fined not more than 510,000 or imprisoned not more than five years, or both. SEE ATTACHMENT ABOUT MDNR PERMIT FEES This information is available in an �, Printed on Recycled Paper altemative format upon reqvest. contains 1o96postcors�ar,erwaste —�