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<br /> APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT(33 CFR 325) OMB APPROVAL NO.0710-003 Ezpires Dec 31,2004
<br /> The public burden for this collection of information is estimated to avenge 10 hours per response,although the majority of appl�cabons should requue 5 hours or less. T1us mcludes
<br /> the time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collcction of information. Send
<br /> comments mgarding this burden estimate or any other aspect of this collection of infoimation,including suggestions for reducing this burden,to Department of Defense,Washington
<br /> Headquarters Service Directorste of Infoimation Operations and Reports,1215 Jefferson Davis Highway,Suite 1204,Arlington,VA 22202-4302;and to the Office of Management
<br /> and Budget,Papenvork Reduction Project(0710-0003),Washingtoq DC 20503. Respondents should be aware that notwitLslanding any other provision of law,no person shall be
<br /> subject to any penalty for failing to comply with a collection of information if it does not display a cunently valid OMB control number. Please DO NOT RETURN your form to
<br /> either oFthese addresses. Completed applications must be submitted to We District engineer having jurisdiction over the location of the proposed activity.
<br /> PRIVACP ACT STATEMENT:Autl�orifies:Riveis and Harbors Act,Section 1Q 33 USC 403;Clean Water Act,Section 404,33 USC 1344;Marine Protection,Reseazch and
<br /> Sanctuaries Act,33 USC 1413,Section 103. Principal putpose:Info�ation provided on this foTm will'be used in evaluating the application for a permit Routine uses:This
<br /> information may be sbared with the Departmeni of Justice and other Federal,state,and local govemment a�encies. Submission of requested info:mation is voluntary;however,if
<br /> information is not provided the permit application cannot be evaluatcd nor can a permit be issued.
<br /> ITEMS 1 THROUGH 4 TO BE FILLED IN BY THE CORPS
<br /> 1.APPLICATION NO. 2.•FIELD OFFICE CODE 3.DATE RECENED 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,atso complete items 8 and 11. This optional Federal form is valid
<br /> for use only when included as art of this entire state a lication acket
<br /> 5.APPLICANT'S NAME 8.AUTHORIZED AGENT'S NAME AND TITI.E(an agent is not required)
<br /> Wayzata Country Club;Bob Distel MFRA:Todd Ullom
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<br /> 11.STATEMENT OF AUTHO� TTON(if appli ble,complete only if authori�ing an agent)
<br /> I hereby authorize MFRA:Todd UII to act on my behalf as my agent in the processing of this application and to fumish,upon
<br /> request,supplemental information' su ort o this pe 't ap lic tion
<br /> APPLICANT'S SIGNATURE: g I DATE: 1� '��'��J
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<br /> 25 rLIS�'O O C3ER{CIFIGA{I'IONS40R�AP,P.RO� +ENLSLSeRECE� -D ERO OTFIERrRED S'I�A OR:��Ca' L�GENCIE sF0
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<br /> 26 Application is eby made for a pernut or permits to authorize the work described in this application. I certify'that the information in this
<br /> ap lication is com le and accurate. I further certify that I possess the authority to undertake the work described herein or am acting as the duly
<br /> u o ed agent o th applicant
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<br /> S�gnature of applicant Date Signature of agent(if any) Date
<br /> 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
<br /> the statement in Block 11 has been filled out and signed. 18 U.S.C.SecHon 1001 provides that:Whoever,in any manner within the jurisdiction of any
<br /> departrnent or agency of the United States lrnowingly and wilifully 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 writing or document knowing same to contain any false,
<br /> fictitious or fraudulent statements or entry,shall be fined not more than$10,000 or imprisoned not more than 5ve years or both.
<br /> ENG FORM 4345,Ju197 EDITION OF FEB 94 IS OBSOLETE. (Proponent:CECW-OR)
<br /> Minnesota LocallState/Federal Application Forms for Water/Wedand Projects
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