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<br /> 1. ProjecUSite Information
<br /> Project/Site Name: p,.��',r ���5 p,,�,ra Local Government Unit: C:�y ef �,�,,,,o
<br /> Location (address and/or T, R, Sec.): -7'��gy,t� �22,3G�J J�/r•✓�/¢, aE S-�• 3�
<br /> 2. Applicant Information
<br /> Applicant Name: g� ���s� Address: �Zs�(,1G�-�/l� ��
<br /> City, State, Zip: pv,r,���J ��N ��_�1��
<br /> E-mail: b,jotiNa-o.� QS't'�jo:+,�J. co,•,� Phone: �IZ-- 3G� — 9'77¢
<br /> 3. Agent/Consultant Information
<br /> Company Name(if applicable):���s,o,,, ��;,,,�,�,,�,�'�ontact Person: ��,,,� ����
<br /> Address: 5g� ( �v..�1rok-} �`�f City, State, Zip: 8,.�,�j�� ��t,�j�/
<br /> 3`S¢-3a
<br /> E-mail: `jR�b�.,.,�.*v� ►�v�srl, ��q,r,� Phone: �012 —�`D2 �1o6/q
<br /> 4. Description of Request
<br /> Check all that apply: f�.Wetland Boundary (must attach wetland delineation report)
<br /> �Wetland Type (Eggers & Reed and/or Circular 39 type)
<br /> 5. Signature
<br /> By signature below, the applicant requests a determination 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 /> landowner to pursue this determination.
<br /> � �/3/2oi3
<br /> Applicant r Autho d Agent 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 with your LGU regarding their submittal requirements.
<br /> • The LGU decision must be made in compliance with Minnesota Statutes, section 15.99.
<br /> For LGU use only
<br /> Date Received:
<br /> Page 1 of 1
<br /> BWSR Wetland Boundary/Type Application Form 11/10/08
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