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, � • � INSTRUCTIONS--PLEASE READ CAREFULLY . A copy of this form, with copies of all plans, drawings, etc., should be sent to each agency indicated below. Please check the appropriate spaces below to show everywhere you are sending this form. Remember to keep a copy fo�you�records. LOCAL GOVFRNMENT UNR (LGU): city, county, or watershed management organization. Specify the LGU to which you are sending the form: � The IOC21 SOIL AND WATQi CONSFRVATION DISTRICT (SWCD) fOf the pfOjeCt. Specify the county SWCD: W,ar�sHen DisTRicr (if one,exists for the project area). Specify the Watershed District: MINNESOTA DEPARTMENT OF NATURAL RESOURCES (MDNR) feg101121 office U.S. ARMY CORPS OF ENGINEEfiS(CORPS). Send th@ CORPS COPy t0: Department of the Army, Corps of Engineers, St. Paul District, ATTN: CO-R, 190 Fifth Street East, St. Paul, MN 55101-1638 Note: The above agencies may provide a copy of your completed form to the Minnesota Pollution Control Agency (MPCA). MPCA water quality rules may apply to your proposed project. ATTENTION (FRonn USDA1: Any activity including drainage, dredging, filling, leveling or other manipulations, including maintenance, may affect a landuser'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. IMPORTANT: Some agencies, including the Corps of Engineers and the MDNR accept this form as a permit application form. If you wish this form to constitute an application to the Co�ps and/or MDNR for any necessary permits for your project please carefully read the following information and sign where indicated. YYYYZYYZY%Y%Y%YYY%Z%YYYYY%%YY%YYYYYYY%YYYYYZZYYYYYYYZZYYZ%ZYYYYY Application is hereby made for a permit or permits to authorize the activities described herein. I certify that I am familiar with the information contained in this application, and that to the best of my knowledge and belief such information is true, complete, and accurate. I further certify that 1 possess the authority to undertake the proposed activities or I am acting as the duly authorized agent of the applicant. ��c2G /- d / 9 s� � Signature of plicant Date Signature of Agent Date Note: The application must be signed by the person who desires to undertake the proposed activity (applicant) or it may be signed by a duly authorized agent if the info�mation requested below is provided. AgenYs Name and title: AgenYs address: Agent's telephone: ( ) 18 U.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction of any department or agency of The United States knowingly and willfully fa�sifies, conceals, or covers up by any trick, scheme, or device a material fact or makes any false, fictitious or fraudulent statements or representations or makes or uses any false writing or document knowing 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. SEE ATTACHMENT ABOUT MDNR PERMIT FEES . This information is available in an « p�nted on Recycled Paper altemative format upon request. contains to96postcoruur„erwaste