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I , <br /> w ►I - I� . <br /> . . . . . � . <br /> � �• . • • � �• • . � � •- • :• •. <br /> 1. Project/Site Informafion D � � 2 n nn � <br /> �� u u <br /> Project/Site Name: 400 Willow Dr'ive South Local Government Unit: MCW <br /> . ' SEP � 92011 <br /> Location (address and/or T, R, sec.): T117N R23W S03 <br /> � <br /> � 2. Applicant information <br /> Applicant Name: Mark J. Nelson Address:809 Halsey Avenue SE <br /> City,State,Zip: Buffalo, MN, 55313 <br /> E-mail: mark.nelson@roche.com Pnone: (763)477-6451 � <br /> 3. Agent/Consultant Information <br /> Company Name (if applicable):SER Contact Person: David Haar <br /> � Address: 25580 Nelsine Drive city, state,zip: Shorewood, MN, 55331 � <br /> E-maii: davidh@gpsinnovations.com Phone: (952)471-1100 <br /> 4: Description of Request <br /> Check all that apply: �Wetland Boundary(must attach wetland delineation report) <br /> �Wetland Type (Eggers & Reed and/or Circular 39 type) � <br /> 5. Signature <br /> By signature below,the applicant requests a determination from the Local Government Unit under <br /> Minnesota Rules 8420.0225 on the submitted wetland boundary and type information in this application. <br /> The applicant also affirms that they are the owner of the subject property or have permission from the <br /> landowner to pursue this determination. <br /> +.LJC:D�i�`)�(.�.�-�- ( / �S / I� <br /> Applicant or Authorized Agent Signature Date <br /> Important Notes: <br /> • The applicant may be required to submit multiple copies of the report/information to the <br /> LGU.The LGU may require the applicant�o submit copies directly to Technical Evaluation <br /> Panel Members. Check wlth your LGU regarding their submltfa/requirements. <br /> • The LGU decision must be made in compliance with Minnesota Statutes, section 15.99. <br /> For LGU use only SE� � � 201i <br /> Date Received: <br /> Page 1 of 1 <br /> BWSR Wetland Boundary/Type Application Form 11/10/OB <br />