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R���I�I�D <br /> UtL c � �3 <br /> 1NSTRUCTIONS-PLEASE READ CAREFULLY G17Y UF ORQNO <br /> A copy of this form,with copies of all plans,drawings,etc... should be sent to each agency indicated below. <br /> Please check the appropriate spaces below to show everywhere you are sending this form.Remember to keep a <br /> copy for your records. <br /> ✓ The LOCAL GOVERNMENTAL UN1T(LGU)city,county or water management organization <br /> ✓ The SO1L&WATER CONSERVATION DISTRICT ✓ HENNEPIN SWCD CARVER SWCD <br /> ✓ MINNESOTA DEPARTMENT OF NATURAL RESOURCES (MDNR)Regional Office <br /> '� US ARMY CORPS OF ENGINEERS(ACOE)at: Dept. of the Army,Corps of Engineers, St.Paul <br /> District-ATTN: CO-R, 190 Fifth St. East,St.Paul,MN 55101-1638 <br /> Note:T'he above agencies may provide a copy of your completed form to the Minnesota Pollution Control <br /> Agency(MPCA). MPCA water quality issues may apply to your proposed project. <br /> ATTENTION (From USDA):Any activity including drainage,dredging,filling,leveling or other manipulations, <br /> including maintenance,may affect a landuser's eligibility for USDA benefits under the 1985 Food Security Act <br /> as amended.Check with your local USDA office to request and complete Form AD-1026 prior to initiating <br /> activity. <br /> IMPORTANT: Some agencies,including the Corps of Engineers and the MDNR accept this form as a permit <br /> application form.If you wish this form to constitute an application to the Corps and/or MDNR for any necessary <br /> pernuts for your projects please carefully read the following information and sign where indicated. <br /> ���������������������������������������������������������������������������������� <br /> Application is hereby made for a permit to authorize the activities described herein. 1 certify that I am familiar <br /> with the information contained in this application,and that to the best of my knowledge and belief such <br /> information is true,complete and accurate.l further certify that 1 possess the authority to undertake the proposed <br /> activity or 1 am acting as the duly authorized agent of the applicant. <br /> c� ; � ' <br /> ���✓�%� ' c�'C �C'� <br /> Signature of Applicant Date Signature of Agent Date <br /> Note: The application must be signed by the person who desired to undertake the proposed activity <br /> (Applicant)or it may be signed by a duly authorize agent if the information requested below is provided. <br /> Agent's Name&Title: ��/� t�R..� �n Cr�dC <br /> Agent's Address: �a �OX �la 7 Wf�''�er�ew/1 /�N �S 3�� <br /> Agent's Telephone: ((of2 ) ��g ' q`'�°2� <br /> 18 U.S.C. Section 1001 provides that: Whoever,in any manner within the jurisdiction of any department or <br /> agency of the United States knowingly and willfully falsifies,conceals,or covers up by any trick,scheme,or <br /> device a material fact or makes any false, fictitious or fraudulent statements or representations or makes or uses <br /> any false writing document lrnowing same to contain any false,fictitious,or fraudulent statement or entry,shall <br /> be fined not more than$10,000 or imprisoned not more than five years,or both. <br />