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__ __ <br /> � Proj�ct Name andjcr Number ,'0� Jickey Lake �r ve <br /> PART �NE: Applicant Information <br /> I!applicant s an entity(cnmpany,govPrnm�nt entity, partn�rshlp,etc.), an aulhorized conlacl peison rnu5l be idenlif,ed. I( lhe <br /> applican;is using ac �gen: (ccnsultant; lawyer, or other third party} and has authorized them to act en:heir behalf, the a�,ent's <br /> .ontact informa-ion must also be provided. <br /> ApplicantfLand�wnerName: KarerPuKh <br /> Mailing Address: A5?4 f3irr_hmont Drive NE�il"? Bemidji, MN 56601 <br /> Phone� r7E-4U7•pZD7 <br /> E-mail Address: karenp�:�ns�ack.com <br /> Authorized Contact(do not comp{ete if same as above): <br /> Mailing Address: <br /> Phone: <br /> E-mail Address: <br /> AgeM Name: Ben Cai i5on <br /> Mailing Address: 251�5 Wild Rose LanE <br /> Phone: 352-401-8757 <br /> E-mail Address: ben��kjvlliaugenv.corT� <br /> PART TWO: Site Location lnfarmation <br /> County: Hennepin City/Township: Orono <br /> Parcel ID and/or Address: 3411823220005 <br /> Legal Description (Section,Township, Range�: 5:34 T:i18N R:23W <br /> lat/Long(decimal degrees): 44.991572, -93.582869 <br /> Attach a map showing the location of the site in relation to local streets,roads, highways. <br /> Approximate size of site(acres}or if a linear project, length(feet): 2.45 <br /> I�you kno�,v thal yuur �reposal vriU reyuire an indiv+dual Permit from the U.S.Army Corps of Enginee�s,ycu rnust provide the <br /> names and addresses ot all property owners adjacent to the project site. This information may be provided by attaching a list to <br /> your applicalion or by usink block 25 ot the Application ior Department of the Army peimil which can be ablained at: <br /> httu:/,%www.mvp.usace.a�mv.mii!Portalsi57%doc�'re�ulato�y;�RegulatorvDocs/en�torm 4345 2G12oct.pdt <br /> PART THREE: General Project/Site Information <br /> I'�lhi� �pplication fs related to a delin:-a,icn auFic.�vd , txernption deterrnination,jurisdic?�cnal de;er--iinalion,or other <br /> corresponden�e submitte�prior to this appl'ca:ion tnen describe that here and provide the Corps of Engineers project number <br /> Describe the project that is beinE prcpose:�l, the prc�ject purpose 2nd need, and scr�edule f�r implementation and completien The <br /> pro;ec:descript�on must fully describe t7e nature and scope of the preposed a�tivity mclud�n�a Jcscription of a�l praject elerlients <br /> that e"ect aquatic resou�ces (wetland, lake,tributary, etc j and must alsa include plans and cross sect�on or p-of�le drawin�s <br /> �t�ow ng the �oc:ation, characler, and dimen,ions of all propased activitics and aquatic rescu�cc impacU. <br /> t�1 nnesota Interagency 1,'v'ater Resource,lpp�icatia�� Form Feb�uary 2014 Pa�e�of 11 <br />