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�"1 �h INSTRUCTIONS—PLEASE READ CAREFULLY A copy ofthis form,with copies of all plans,drawings,etc... may need to be sent to an agency indicated below... Please check the appropriate spaces below to show everywhere you are sending this form.Remember to keep a copy for your records. ❑ MINNESOTA POLLUTION CONTROL AGENCY(MPCA)for NPDES phase II permit �The LOCAL GOVERNMENTAL IJNIT(LGU), city, county or water management organization �MfNNESOTA DEPARTMENT OF NATURAL RESOURCES (MDNR)Regional Office 0 US ARMY CORPS OF ENGINEERS(ACOE)at Dept. of the Army,Cotps of Engineers, St. Paul District ATTN: CO-R, 190 Fifth St. East,St. Paul, NIN 55101-1638 Note:The above Agencies may provide a copy of your completed form to the Minnesota Pollution Control Agency(MPCA). MPCA water qualiry requirements may apply to your proposed project. ATTENTION(from USD.A):Any activity including drainage,dredging, filling,leveling or other manipulations, including maintenance, may affect a land user's eligibility for USDA benefits under the 1985 Food Security Act as amended.Check with your local USDA office to request and complete Form AD-1026 prior to initiating activity. Application is hereby made for a permit to authorize the activities described herein. 1 certify that 1 am familiar with MCWD Rules and that the proposed activity will be conducted in compliance with these Rules. 1 am familiar with the information contained in this application and,to the best of my knowledge and belief,all information is true, complete and accurate. 1 further certify that f possess the authority to undertake the proposed activity or 1 am acting as the duly autharized agent of the applicant. . �� a,��.� �a)ao �o Signature of Applicant(Property Owner) Date �gnature of Agent Date NOTE: The application must be signed by the property owner where the proposed activity is to occur.The application may be signed by a duly authorized agent if a letter bearing the original signature of the property owner is submitted stating that the agent noted in the permit application is the authorized agent of the landowner for all matters relating to the permit. Please provide authorized agent information below: Agent's Name&Title: ��c'�� — ��` � �1' ► PiV Agent's Address: ��SJ� 1'LI�IA$� �� V U�`�V 1� � ��_1�( Agent's Telephone: �) ��lp"��,� 18 U.S.C. Section 1001 provides that:Whoever, in any manner within jurisdiction of any department or agency of the United States knowingly and willfully falsifies,conceals or covers up by any fick,scheme,or device a material fact or makes any false, fictitious or fraudulent statements or representations or makes or uses any false writing document kno�Ning same to contain any false, fictitious,or fraudulent statement or entry, shall be fined not more than$10,000 or imprisoned not more than five years,or both. Page 2 of 2