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. o � • o ' <br /> � 0 0 6 0 0 � 0 0 0 • � . 0 • 0 :. 0 9 � �$ t��,A <br /> ...._r __,.. a . � <br /> 1. Project/Site Information <br /> Project/Site Name: 1685 Fox Street Local Government Unit: Orono <br /> Location (address andlor T. R, Sec.): 1685 Fox Street Orono, MN 55356 <br /> 2. Applicant Information <br /> Applicant Name: Nivin Macmillan Address: 1G85 Fox Street <br /> City, S1ate, Zip: Orono, MN 55356 <br /> E-mail: Phone: 952-473-3400 <br /> 3. AgentlConsultant Information <br /> Company Name (if applicable): �f�R Contact Person: Frank Svobod� <br /> Address: 25580 Nelsine nrive Ciry, Staie. Zip: Sf�orewood, MN 55331 <br /> E-maiL fr�nks@gpsit�nov��tiot�s.c,om Phone: 952-411-1100 <br /> 4. Description of Request <br /> Check all that apply: CX7 Welland Boundary (must altach wetland delineation reportl <br /> L�Welland Type (Eggers & Reed and/or Circular 39 type) <br /> 5. Signature <br /> By signature below, the applicanl requesis a determination from the Local Government Unit imder <br /> Minnesota fiutes 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 ihe <br /> landowner io pursue this determination. <br /> � i� ►�,u.�.. ,�.L�<l?��<�R_ ��L.,.,, �, l.��1 l -- <br /> Applicant or Auth ized Agent Siynature Date � <br /> Important Notes: <br /> • The applicant may be required to submit multiple copies o( the report/in(ormaiion to the <br /> LGU. The LGU may require lhe applicanl lo submit copies directly to Technical Evaluation <br /> Panel Members. Check with your LGU regarding fheir submittal requiremenfs. <br /> • The LGU decision must be made in compliance wilh Minnesota Stalules, seclion 15.99. <br /> For LGU use only <br /> Date Received: <br /> Page 1 of 1 <br /> BWSR WeUand 6oundary,'Type AF�plicalion Form 11;10'O8 <br />