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w�D-ll� <br /> - . . - . - . � <br /> . . . . . . - . .- . . :. <br /> 1. ProjecUSite Information <br /> ProjecUSite Name: 3675 JaCobs Mill Rd. Locai Government Unit: MCWD <br /> Location (address and/or T, R, Sec.): 3675 Jacobs Mill Rd., Orono MN 55356 <br /> 2. Applicant Information <br /> Applicant Name: Jeff Ament Address: 3675 JaCobs Mill Rd. <br /> City,State, zip: Orono, MN 55356 <br /> E-mai�: jeff.r.ament@gmail.com Phone: 952-239-9300 <br /> 3. AgenUConsultant Information <br /> Company Name (if applicable): SER contact Person: Brian Burgner <br /> address: 25580 Nelsine Drive, Suite 100 city, state,zip: Shorewood MN, 55331 <br /> E-maii: brianbC�gpsinnovations.com Phone: 612-790-5511 <br /> 4. Description of Request <br /> Check all that apply: �Wetland Boundary(must attach wetland delineation report) <br /> f�Wetland Type (Eggers& Reed and/or Circular 39 type) <br /> 5. Signature <br /> By signature below,the applicant requests a deterrnination 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 /> lando r to pursue thi det ination. <br /> �o - �9- 2cf�a <br /> Ap ' nt or thori t 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 to submit copies directly to Technical Evaluation <br /> Panel Members. Check wifh your LGU regarding their submiital req�irements. <br /> • The LGU decision must be made in compliance with Minnesota Statutes, section 15.99. <br /> For LGU use only <br /> Date Received: OCT 'L 1 2010 <br /> Page 1 of 1 <br /> BWSR Wetland Boundary/7ype Application Form 11/10/08 <br />