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. � IIVSTRUCTIONS-PLEASE READ CAREFULLY A copy of this form,with copies of all plans,drawings,etc...should be sent to each ageacy indicated betow. Plcase chxk the appropriate spaces below to show everywhere you are sending this form.Remember to kcep a copy for your records. � The LOCAL GOV'ERNr�1VTAL UNIT(GGin city,county or water manage�nt organization The SOII.&WATER CONSERVATION DISTRICf _ HfENNEPII�1 SWCD CARVER SWCD MIlVNFSOTA DEPARTMF.NT OF NATtJRAL RESOURCES(IVIDNR)Regional Office US ARMY CORPS OF ENGII�IEERS(ACOE)at:Dept.of the Army,Coips of Eagineers,St Paul District-ATTN:CO-R. 190 Fifth St.East,St.Paul�MN SS101-1638 �;The above agencies may provide a c�y of your completod form to the Minnesota Pollution Cantrol Agency(MPCA).MPCA water quality issues raay apply to your proposed projec� AT1'EIVTION(�om USDAI:Any activity including drainage,drodging,filling,leveling or otber manipulatioas, including maintenarxx,may affect a landuser's eligibility f�USDA benefits nnder the 1985 Food Security Act as ameaded.Chxk with your local USDA office to request and compl�te Form AD-1026 prior to uutiating acdvity. IIVIPORTANT:Some agencies,including the Ccups of F.nginoers and the I�IDNR acxept this form as a penmit application form.If you wish this form to coastitute an appGcation to ttre Corps and/or MDNR for any necessary pennits for your projects pkase cazefully read the following information and sign where indicatod. Application is he�reby made for a permit w anthorize the activides desctibed herein.I ceriify that I am familiar with the information contained in this application,and that to the best of my knowledge and belief such infamiarion is trae,complete and accurate.I further ceRify that I po�sess the authority w undertaka the proposed acti ' or I am the duly authorized agent of the app' � �3 Signature of Applicant Si of Agatt Note:The applicarion raust be signed by the person who desired w undertake the propc�sod activity (Applicant)or it may be aigned by a duly authoriu agent if the informatia�roquested below is provided. AgenYs Name 8t Tide:�1rts� t�s � �«,t�$Aaa�: 3?7S G. R.4 S� .. ��.._ .. s�-1s-f AgenYs Tekphone: (Gl.? ) �8e?-�!/f�' 18 U.S.C.Sec.tion 1001 provides tisat:W6oever,in any manner within the jurisdiction of any department or agency of the Unitcd States la►owingly and willfully falsifies,conceals,or covers up by any trick,schc�e,or device a material fact or makes any false,fictitious or fraudulart statements or ropreaentationa or makes or ases any false writing d�ocument knowing saau to contain any false,fictidous.or fraudulent statement or entry,shall be fined not more than S 10,000 or imp�iso�d not more than five years,or both.