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�...., r � � � <br /> ! ' � <br /> INSTRUCTIONS—PLEASE READ CAREFULLY <br /> A copy 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 are sending this form.Remember to keep a copy for your records. <br /> � MINNESOTA POLLUTION CONTROL AGENCY(MPCA)for NPDES phase II pernut <br /> � The LOCAL GOVERNMENTAL UNTT(LGU),city,county or water management organization <br /> f�MINNESOTA DEPARTMENT OF NAT[JRAL RESOURCES(MDNR)Regional Office <br /> 0 US ARMY CORPS OF ENGINEERS(ACOE)atDept.of the Army,Corps of Engineers,St.Paul District <br /> ATTN:CO-R, 190 Fifth St.East,St.Paul,MN 55101-1638 <br /> Note:The above Agencies may provide a wpy 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 other 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 acrivity. <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 /> �~���d'( �"�`,��iu��S /S,�U�'%' <br /> Signature ofApplicant(Property Owner) Date� ' Signature ofAgent Date <br /> NOTE:The application must be signed by the property owner where the proposed activity is to occur.The application 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 permit application is the authorized agent of the landowner for all matters relating to the permit.Please � <br /> provide authorized agent information below: <br /> AgenYs Name&Title: <br /> Agent's Address: <br /> Agent's Telephone:�� <br /> 18 U.S.C.Section 1001 provides that:Whoever,in any manner within jurisdicrion of any department or agency of the United <br /> States knowingly and willfully falsifies,conceals or covers up by any trick,scheme,or device a material fact or makes any <br /> false,fictitious or fraudulent statements or representarions or makes or uses any false writing document knowing same to • <br /> contain any false,ficritious,or fraudulent statement or entry,shall be fined not more than$10,000 or imprisoned not more than <br /> five years,or both. <br /> Page 2 of2 <br />