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ProJect Name and/or Number; ����_�� <br /> i <br /> PART FOUR; Aquati�� Resource Impactl Summary � <br /> If your proposed proJect Involves a direct or Indirect impact to an aquatic resource ;wetland, lake, tributary, EtC,) Identify each <br /> Impact In the table below, Include all anticlpated Impacts, Including those expected to be temporary. Attach ��n overheac vlew � <br /> map, aerlal photo, and/or drawing showing all of Che aquatic resources In the pro)ect area and the Ioca:ion(s) cf the pro;�osed I <br /> Impacts, Label each aquatic resource on the map.with a re�ference number or letter and Ldentify the Impacts In th�following�;able. <br /> A Type of Impact Duration of C��unt J <br /> quatic Exlsting Pl�nt Y� Ma or <br /> Aquatic Resource fill, excavat2, <br /> Resource Type .�� Impact Overall Slze of VVatersF�ed �, <br /> ID(as noted on draln or Permanen+.�P) Size of Impact' A uatic Community and 8��nk <br /> overhead vlew �Wetland, lake, ' q <br /> � remove, or Ternporary Resource 3 Type(s) In i Servlce E;rea � <br /> tributary etc,) imp�c:Area S <br /> vegetatlonj (T)' of Impad Area <br /> llf impacts are temporary;enter the duratlon of the Impacts Ir:days next to the"T", For example,a proJect wlth a temK�or.ary;�ccess flll tha: <br /> would be removed after 220 days would be entered"T(220)", <br /> Zimpacts less than 0,01 acre should be reported In square feet. Impacts 0,01 acre or greater shouid be reported as ac:res and rounded to the <br /> nearest 0,01 acre, Trlbutary impacts must be reported In Ilnear I'eet�i Impact and an area of Impact by Indlcating flrst the Ilnear fe�;t of Im{�act <br /> along the flowllne of the stream followed by the area Impact In parentheses), For example,a pro�ect that Impacts 50 feet of a stream that Is 6 <br /> feet wlde would be reported as 50 ft(300 square feet), <br /> 37h1s Is generally only appllcable If you are applying for a de minimis exemptlon under MN Rules 8420.0420 Subp.8,c�therwise enter"N/A" <br /> QUse Wetlond Plants and Plant�'ommunity Types oJ Mfnnesota and Wlsconsln 3`d Ed.as modlfled In MN Rules 8420.040i Subp 2. <br /> SRefer to MaJor Watershed and eank Servlce Area maps In MN Rules 8420,0522 Subp.7, <br /> If any of the above Identifled Impacts have already occurrE;d, Identify which impacts they are and the clrcurristanc�s assoclated <br /> with each; <br /> PART F1VE; Applicant Signature <br /> ❑ Check here If you are requesting a pre-appllcatlon consuftatlon with the Corps and LGU based on the In1'ormaticn��ou have <br /> provided. Regulatory entltles wlll not inittate a formal appllcatlon revlew if thls box Is checked, <br /> By slgnature below,I attest that the Informatlon!n thls ap�llcation Is complete and accurate, I further attest that I possess th= <br /> authorlty to undertake the work described hereln, <br /> ignature; � <br /> Date: <br /> I hereby authorize,__.�,� _.._ �itr�t.� ., ,to act on my behalf as my agent In the proc:e;•sing of thls appllc�tlon <br /> and t urnish, upon request,supple�mental Informatlon in suppert of thls appl�catlon <br />'The term"Impact"as used In this Jolnt appllcatlon form Is a generlc term used for d!;closure purposes to Identify <br /> activitles that may requlre approval from one or more re�;ulatory agencles. For purposes of this form It ls not meant to <br /> Indlcate whether or not those activities may requlre mitl�;atlon/replacement, <br /> Minnesota Interagency Water Resource Appllcatlon Forr�February 2014 <br /> Page 5 of 13 <br />