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• • .i ti. <br /> S <br /> FOR LGU USE ONLY: <br /> Determination for Part 1: ❑ No WCA Jurisdiction <br /> ❑ Exempt:No._(per MN Rule 8420.0122) <br /> ❑ No Loss: _(A,B,...G,per IvIN Rule 8420.0220) <br /> ❑ WeBand Boundary or type <br /> ❑ Replacement required—applicant must complete Part II � <br /> COMPLETE THE SECTION BELOW ONLY IF REPLACEMENT IS NOT REOUIRED: <br /> Application is(check one): ❑Approved ❑Approved with conditions(conditions attached) ❑Denied <br /> 'Comments/Findings: ' � <br /> LGUo�cial signature Date � <br /> . Name and Title <br /> For Agricultural and Drainage exemptians(MN Rule 8420.0122 Subps.1 and 2B),LGU has received proof of recording of restrictions <br /> (per MN Rule 8420.0115): . <br /> Counry where recorded Date Document#assigned by recorder . <br /> • LGU official signature Date <br /> � �Minnesota LocaUState/Federal Application Forms for Water/Wetland Projects <br /> Page 3 <br />