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NA-02622-02 <br /> •Rev. �2�81 PERMIT APPLICATION PART A OFFICE USE ONLY. <br /> Df PA R TM E N T o F TO WORK IN PROTECTED WATERS OR WETLANDB ' P•A. N0. <br /> [�a��o��a <br /> N AT U R A L R E S O U R C E S (�NCLUDIN6 DAM SAPEfl) <br /> []SWCD �C/C <br /> ►►Please read instructions before attemptirig to complete this application. ❑W•�• DU�� <br /> I. Applicant's Name (Last, First,.M.I.) Authorized Agent (if applicable) �Elephone Number�area <br /> :�t:Ir. R�i�x"3.� �t a�. ��t& �b�2 � 2-� � <br /> Address (Street, RFD, Box Number, City, State, Zip Code) <br /> 14b� � 14fi�$ Lc�mr� Lf�s ���ud., 4�zt. 553� <br /> overn ent L (s) Quart r Section(s) Sectio (s) Township(s) Range(s) Lot Block, Sub-Division <br /> � � � � �� � ��'t 23 �8 �.#�� <br /> Fire No., Box No. or Project Address County Project will affect Lake,Wetland or Watercourse <br /> �►i�i9tlt �gg�gjt,n, (name8�number, �{��; �� �� <br /> if known <br /> II. PROPOSED PROJECT III. PROJECT AREA <br /> ❑ fill ❑ excavate ❑ dam ❑ culvert �t shore-protection <br /> ❑ drain �construct O lake ❑ wetland ❑ other (specify) <br /> ❑ remove ❑ other (specify) ❑ wharf ❑ shoreline <br /> ❑ abandon ❑ bridge ❑ obstruction <br /> ❑ install ❑ harbor o watercourse APR 2 � <br /> IV. ESTIMATED PROJECT COST ❑ riprap � sand blanket 4 ig�5 <br /> $ ❑ channel � permanent dock ������ � <br /> V. BRIEF EXPUMATION OF PROJECT . <br /> ��.c� � git1.� �ic�� o� #rhe pr�aper�ty l�t� b�'��e� +�� lt>t� �td pla�e <br /> s�i.�+ r�p� �.��g 1�} ft. af �horer�.i�� <br /> VI. JUSTIFICATION (Explain why this project is needed) <br /> �e �c�!'�tcc�� �f '�e 3�c� i.� ��� a�d 't�e te��rury dt��k �a�t� �o►�i� lo�s� <br /> sad � ha�r� h� � � '�e tr. <br /> The �rip rsp� �3.1 �ia].p �tset a�:isc�� �r4ai��t. <br /> YII. ENVIRONMENTAL IMPACT (Anticipated changes to the �►ater and related land resources, including unavoidable but detrimental effects) <br /> �� <br /> VIII. ALTERNATIYES (Other alternatives to the action proposed) <br /> �� <br /> �x. I hereby make application pursuant to Minnesota Statutes Chapter 105.42 and all supportir►g rules for a permit to work in or atfect the above named protected <br /> watens)in accordance with all supporting maps,plans,and other iMormation submitted with this application.The information submitted and statements made <br /> concerning this application are true and correct to the best of my knowledge. <br /> Signature of Owner or Authorized Agent Date; � ,,.�� ,_ <br /> STATE OF �.�2136l�iA'�qL �i:......`. � �':�+,:.� �.. s , .,. -,. ,,,,.;, <br /> GOUNTY Of ���?f 3�. Si ure o� easee Date <br /> ....�- <br /> Subscribed and sworn to before me this <br /> '��,, Uistribution: <br /> �day of ���"�.� 19� �C�t✓'1,�..�«'� ����_ � '�� ' :' �'_�: DNR <br /> - Blue: SWCD <br /> My commission expires���E 3, 1��� Green: Watershed District <br /> " � Goldenrod� City Or County ` <br /> ����� <br /> : ' a e of No�.��" � �"�'� -�:��,.--.�r�,-f .� �����'��` Plnk: Army Corps of Engineers <br /> �' �c���,�� s x� Canary:Applicant _ <br />