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<br /> API'LICATlONt FOR BEPART�tiZENT O�Tf1E ATi,'4IY P,BBi41IT C�tc325 OFIt3AflPR0�'AL 3��.0710•003 E '
<br /> 7Lo pubtie bvrdca Cer tnfis co]itttEoa of iafamztfan fs cstiassted to s��e 10 h3tax per nsponse,d�bcu�h�t�majority of appiiratioas shoc4l cequire 3 hoitts oc s. etu s
<br /> the Iieu fw revie��ing i¢struction;searehiae cxistfngdat�saurtts,�f6sri��aui!mainf¢iniag tAo daG[mrdrd;and compielmg aad��ic�it�t6o cotlecifo�atinEmwlian Scisd ,
<br /> ecminrn:smgsrdia�this6urdrncstimstoorzqyolhr��spectotth;smttcclionofirttatmatton.inotu8in su
<br /> Fleafl�wctcrt5rn9ceDirceeora�noflnfanaaiins B 86'�slioasfwrcdu:iasthis6ucdea.toDepa�tmectotDeteaer,lYashiagtas '
<br /> ��tt,� Opentioas a�W ReQc:ts,12[S7tii2rsa�Datis Ftl�.kiray,Suife 120�,Arliag:ca,VA 22202.630i;aad to Ihe alfico ofl�fnmga;t�nt
<br /> S ��rorf:RectQ;tFas Pr�eet(47t0•0003),Was6ington,I7C20S0�,kespnndems s�ould 1�a+care unc nau4ithstandinE�Y+�'�erprovision ef)a�v,na peuon ihatt!x _
<br /> st�;ett w any peaaky for f�ilinG w eo�pph tisi�a eolkNioa of infonnetioa iCiC dxs»oi display a e�arcatiy�alid Olip eo�cot nivabtr.p{eue pp rpT�U��,�fo�m w
<br /> eiqrerotlhesc addrcsses: Caapttted epplic�ions umsl pe sQymftted m tke DIstrici enginearfwti6ag jurisdicliono�er�hc locatisn eE�hepra�qsui art;rety.
<br /> Pltt�'ACY AGT ST.tTE�1tE�T:Aufho�iiier.Rit•era aod flicL•ars Are,Set��ou t0,33 USC A03;ClraiF t1�s(er Ac1,Seruo»Q��3�USC t344;1�iazine Protection,R�eb�
<br /> SaeKiouies het,33 USG 14U,Section lQ3.l�u�eipnF pwposa lu(�� aidcd ott tAis fortrt FrTf be ussQin e�nlwtin tha cuian toc a nni4 Routine uses:iL'u
<br /> inforawl:oa may Le stisred uzlk thaD � E IIPPh
<br /> �F�tmrnt afJastirc and ether Fedecal,state,and local gmemmtat a encies.S•a6missian of rc neatcd fnfoe uion is�a1un
<br /> ieformiiaaisr,ot aided .e icatianeanaat6eevatuaSe norexna anitEetssxd e 4 �:�r�v.if
<br /> ITEMS 1'fHRQU�H 4 TO B��ILLED IN BY THE CORPS
<br /> 1.APPLiCATIQN�0. 2.F[ELD OFFICE CODE 3.DA'C'E RECEIVF..n . °
<br /> 4.DA'fE APPUCAT101�C(3�fpLE7E�
<br /> YOU DO NOT NEED TO COMPLETE ITEI{l1S 6-'[0 at�d q2_2&tn the SHADED AREAS.
<br /> �ilf upp[icnnts must compictc non•sl►ndect Itcnts S:tnd 2G. If nn ngc�tt is used,atso complete ftcros 8 tuid 1 l. This optional Federa(fornt is t•Alid
<br /> far use ojt��ttihen Ineiuded n§ act ot'thts tntire state a ltcatfott acket.
<br /> 5.APPLtCAtdT'S NAMC: 8.AUTWORI'I.Et7 AG�NT'S NAME RNp TiTLE(�u�agent h not requircd)
<br /> Wayzata Cauntry Gtutr;Bnb Distel MFRA,;Todd Ullom
<br /> 6 APP.�,ICAN£'Si1DDl2ES�` 'r n�.a � r+'' �' ` • ,,: r x
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<br /> 9 AE3E1vT S�ADDRESS�� '; �`,, �'' s ; 's
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<br /> 7 APPLICANT'SPH0��161�l0 ` ' �° ..s;,��` �lO�AG�{'f�SPHONEI�ip , r? i , , ,
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<br /> I1.STATE111E\TOFAUTI[dRlZA�10 `(InPP k:co �plcteoulp ni�lkorlsi�rgarrabarNJ �
<br /> 1 herebp autt�orize MFRA;Todd Ullo � � l� t on n�y Gtf�nlf ns ml�egcnt i�Uie procrssing of this epplication nnd lo furn[sh�upon
<br /> rtqucst,supplentcntal tnConnation[n oftlits�e nppti iia� �
<br /> APPLlCAI�T"S SICr��A7UR�: �
<br /> � � � DATE � � � ��
<br /> 12 PROJEG!`j�T/�I�460RT1TLE(secinsin�ct�ons) , � } r; "s ,r.� �"`* -� r
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<br /> 13 NAME OF 1Yl�TER�ODY,7F L�'ND�tlt�'(Ii'agplic�bio) -} IQ PRQlE �h �' �" ``
<br /> ° p Ga'3T.itEETAbbRESS(�t'appltrnblo) �, >y*� '� '�:r� * :�
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<br /> 15.,LOCA7i0N OF�PRq1ECTi ';��;-' ' � ' ' � � a �= a,.�.� .M;, �.�
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<br /> l 7 DI[tEGTIOHS'i'O THE Sl'F� �',:, ,t � i � �'r °a ' ,.�
<br /> , , '"' 18 NATURG OF ttCt'iV1TY �; � ,' ��_��. ,,°�
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<br /> �79 PROJECT.PURPOSfi ` ' z ``- � ``
<br /> _ .�.� .'[ Y " , �20 REASON E i � + S ,. x { �.
<br /> ($)�FOR D1SCEiARC, .r
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<br /> .21 TYpES OF MttiTERIAL}381hG.I3LSCHA}tGEU A�VD TliE AMQEINT Op�AG'N.TYE'B IP2 GUf3[C YARDS » ����y -x
<br /> 22°SUKFACE�AItEA(N rk�RES OF*1YE't'LsA'fr1D5 Oit dTl=f�R�1fAI'�RS TTILI.BU + A` - K
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<br /> ;23 IS ATIYPpRTtOAt OFTHE�,YORI�;ALREADI'CO1+fPL�TEY 1'�S � ` _�
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<br /> .> _,. 5 Nnr IF YES,DESCRIBE GOMF�LII'fGQ�\YOFtl. _`''",
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<br /> 24 ApDRLSSE�,QI'iAD!`OIN�NOPROPLiR�YO1YNCRS�- �'r � � ' ,� 'r5ri �`�¢ .; a �� . �.
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<br /> ZS 1.iSTfaF O'CH�R GB[tTiNlCATI(ii�$OR ArhRQtrALS/D�tAsC;5 R�CEIVFiD FtiOI�T OI'CiER pBDFR'/IL,STA'['E OR LOC�I[,AQENGIES fOR� ..
<br /> ,}�RI.UESCRiBED IPT}[;H[S�1PE�LtGA?InN' � S "5 4 , ,, , ,�`
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<br /> apptApplication is tiereby�made for s perm�t or permfts to authorize tUa�ti�ark described in t6is npplioation. I certzfy ttint U�c fnfornintlon i�n lhts �
<br /> icati n is comp te nd accurate. I fnrfher certlfj�thet I possess the aathontq to underlake the�vark described t�eretn or am aettng ns Qio dulp
<br /> Al tI10[t2 flgC1iC 0 IItC R pIIC Itt.
<br /> Signat ir Tid(�plicant n Dat�r ��� �f`T'�a`-""---- �'/3-�O
<br /> S gnatare o agent(i nny batc
<br /> 'the appli�atiwi nxist be si�ied by thc persan ti�1io desires to tntdertN:c thc proposed neUt�ity(applicunta,or it mpy�be signed b�•a dul��eulhorized agettc if
<br /> tlie stute�uent in 8(ock t t hes becn filled out aid signed. 16 U.S.C.3eclion 1001 pro�ddes tliat 1�n�oe�•er,in any manne�»ithin U�e Jurisdiciioi�ofnny
<br /> dcpadmant oe agencyof Q�e United SWtes l��ax�ingly And�eitlfully f�lsifics,coaccnls,or col�crs up�vtth png trick,ael�cme,or disgulses a inetcrial fact or
<br /> mal:es any fnlse,fatitious or fraudWent s[ateme�US ot representations or makes or uses nny falstr«Tifiiig or document knotiting s,utte to cantaiu ony fetse,
<br /> ficGlious or fraudulent stnientents vr entry�,slinll be fitfid not nroreil��i SIQ,OQO or iutiprisotted rwl mnra Ilinn 1'iva y�rnrsor both. +
<br /> Et�G FOI��rt 4345,1u197 EtSITCUN�I'Fj;E3 g�t IS UiiSOLG'fL". (Yrapo�tent:C8C11'-p�}
<br /> Minnesot+�LornUStnteJCcdcrpl Applicotion�'ornis for WatcdNcttend Projrcls
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