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_ _ <br /> .. _--_ _- . _-- -- -- ---- ., _ : _-_ _. --__- =------ -:_ - � --� - - . � - <br /> � . - - <br /> _ __� __ . �.._ --�.. . . ...�.:....�.;-,::�.._ <br /> __ �---_-_----_ - - <br /> - ------ .--- -_-�—---- ---- -- a-_�� _ _ <br /> --- - - �--- _ _ �-_,__ -----=- - - ' -, <br /> — - .--- - <br /> _ _ _� ._ .. _ <br /> � - - <br /> ._.� r�.-.�..-_- _ — <br /> - z � <br /> = - - _ _ . _ - - <br /> ---- — --_ - - - f --- ---- - _ --- ,-- - -� - - _ - --- <br /> _ _ . _ <br /> _ _ _ . • <br /> INSTRUCTIONS-PLEASE READ CAREFULLY � <br /> ; <br /> :, . <br /> - A wpy ofthis form,with copies of all plans,drawings,etc...may need to be sent to an agency indicated below...'Please check <br /> the appropriate spaces below to show everywhere you aze sending this form.Remember to keep a copy for your records. _ <br /> ❑ MINNESOTA POLLUTION CONTROL AGENCY(MPCA)for NPDES phase II permit <br /> � The LOCAL GOVERNMENTAL IJNTT(LGin,city,county or water management organization . <br /> �MINNESOTA DEPARTMENT OF NATURAL RFSOURCES(MDNR)Regional Office <br /> --- - - - � -. _. ..._ -. -- _ _ . <br /> 0 US ARMY CORPS OF ENGINEERS(ACOE)at Dept.ofthe Army,Corps ofEngineers,St.Paul District <br /> ATTN:CO-R,190 Fifth St.East,St.Paul,MN 55101-1638 <br /> Note:The above Agencies may provide a copy of your completed form to the Minnesota Pollurion Control Agency(MPCA). <br /> MPCA water quality requirements may apply to your proposed project. <br /> ATTENTION(from USDAI:Any activity including drainage,dredging,filling,leveling or oiher manipulations,including <br /> maintenance,may affect a land user's eligibility for USDA benefits under the 1985 Food Security Act as amended.Check with <br /> your local USDA office to request and complete Form AD-1026 prior to initiating activity. <br /> Application is hereby made for a permit to authorize the activities described herein.I certify that I am familiar with MCWD <br /> _ Rules and that the proposed activity will be conducted in compliance with these Rules.I am familiar with the information <br /> contained in this application and,to the best of my knowledge and belief,all information is true,complete and accurate.I <br /> further certify that I possess the authority to undertake the proposed activity or I am acting as the duly authorized agent of the •: <br /> applicant. <br /> ��l�� ��, '�itic� S /S U�'�' <br /> Signature of Applicant(Property Owner) Dat� Signature of Agent Date <br /> NOTE:The application must be signed by the property owner where the proposed activity is to occur.The applicarion may be <br /> signed by a duly authorized agent if a letter bearing the original signature of the property owner is submitted stating that the <br /> agent noted in the pernut application is the authorized agent of the landowner for all matters relating to the permit.Please ��� <br /> provide suthorized agent information below: : • <br /> AgenYs Name&Title: <br /> _ _ . Agent's Address: - - . _._... . _. _. . - - - - . . _ <br /> Agent's Telephone:�� � <br /> 18 U.S.C.Secrion 1001 provides that:Whoever,in any manner within jurisdiction of any department or agency of the United <br /> -__ �____ States knowingly arid willfully falsifies,conceals or covers up by any trick,scheme,or device a material�fact or makes any <br /> - -� ��- false,fictirious or fraudulent statements or representations or makes or uses any false writing document knowing same to � . <br /> contain any false,fictitious,or fraudulent statement or entry,shall be fined not more than$10,000 or imprisoned not more than <br /> five years,or both. <br /> , <br /> . Page 2 of 2 <br /> • <br />