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•DNR METRO REGION TEL =612-772-7977 Jan 08.96 10=45 No .005 P .03 � <br /> ' 1 TR N �PL R � �� - �/� <br /> .NS^UCTIO S EA►SE D C aEFUL,Y � <br /> A copy ot tMs torm, with copte� vf sil plana, drsw�tps, etc., slwuld be s�nt to each syency Indiwted bdow. Pkase d�eCk the <br /> aAP�oP►iate spaces bdvw to�ow everrwhere vou aro sen�n0 tNs form. l�enrerr►be+to keep�caPf�fO►.Yvur roc�ards. <br /> Locn�,tiovepwY�Nr th�tlti�31: citY,county. or watersMd msnspemsr+t aya��iretion. <br /> Specifr the1GU to wMch you are sen�np the iorm: <br /> Th8 loCel SO1L AND WAT9t OO�M@tVAT101�1 D1�7fUGT(SIMCD!tw tl�e p►OjeCt• • <br /> Specify the countY SWCD: ' ' <br /> WaTeaHEo Dar�acT tff one exists ta the Prolect areal. • <br /> Specify the Wstetshed Qistrid: <br /> V MINnE80TA DEPAN'iMENT Of NATIJRAL REiOURCEi (MIDNR) flQi011i1 O�ICA <br /> U.S. A�nr CoR�oR ENo�N�ri(CORPS). 5a�d tf�e CORPS cvpy to: <br /> DepsrtmenYot ths Army. CwDs o�Enpinea►s. St. Ps�/ Dl�diet, <br /> AT'N:CO-R. 190�Ifq�Street Esst. St. Paul, MN 55101-1838 <br /> N�g: The above agendes msy prw�lc�a copy of yowr eompleted fa►m to the IyU�esota Polludon CoMrvl AOancy iMPCAl. <br /> MPCA wate�quality rulea msY AOp�Y to 1�►propo�ed Prolect• <br /> ATTENTION Jr�w�uSDAI: Any ecRlvlty Inc�udinp draln�p�.tNvdp{rp.NM1nW Nv�lln�v�otAv►n�nip�dsNens. Mckldln0 <br /> mafntanance, rnay sHect a landusv's�IlplblNt►r for tf$bA Mn�fit�w�d�r th� 1885 Fopd Sacwtt�r Aet s�anlN�d�d. t:Mdt wltb <br /> yow focal USbA oNka to nquest and compl�t��orm 4D-1026 prla to InitiAtlnp�cdvity. <br /> � IMPORTAN7: Some ayendes, indu�nQ ths Caps of Ert�ineva u�d ttro MDNR iccepi this form ss s p�mit appNcation form• N <br /> you wish ti�ia form to Constitutt an appiicadon to tlte Cvrps andla MRNR fvr sny rxcessery permits f�rour proJet.t pks�a <br /> tartfuHy resd the fdlowinQ informativrt a�d si�whaz in�cated. <br /> t2ItItSI22T2IiYI�2IIxYII12YIZtYZtYtY=2�YISZIYniutluttlZttll <br /> Application Is hereby mede for a permit q permits to suthorize the sctivities described herein. 1 �riify that 1 am fami�s► wkh <br /> the informat�on contair+ed 'm this application, and tt�at to the best�f mY krrowbdpe and be�t such Mformetbn Is t�ue, <br /> coa+plete. and accwete. t fwti��ertity tt�t i pos�ess the�udw►itlr to undeReke the p►vposad setivkie�a 1 ar►actlr+g ss the <br /> dtdy authajzed apent ot the applicant. <br /> � ������� �,� , <br /> Sipnatwe ot Applicant � DaRe Si�nature ot DatO <br /> I�qtg: The epplication m�ut be apned br#+s Person who dsstros to undertake the propoud ecttvlty faPalcant) a h <br /> may be sf9ned by s d�y sutho�izad aperK it the informati�requested �low b provided. <br /> Ayertt's N�me and title: ��1�:�� �e�el�� �I��(X, IV'ou-�S � u�a�e.�wa� �Iae�u(.s� <br /> A�ent's ad�ess: "t-I Z-� v ��� j _ <br /> €�IQ✓1 {�l ��r t e, �Il� �"��� -- - <br /> A�•S ttk��: {I.�� 8�2-� ��a <br /> 18 U.S.C.S�et�o�1001 provides thst: 1M+oover, in any n+anm.witFan tM juri�dictio�of��r d�pNtm�nt or�pu+ey of Tho UMted Stets� <br /> krwwinply�rrd wiIHulFy falsfies,oo�osd�,or covsn up Dy any triok,�ah�nn,or dwia��m�tRi�l t�ct o�rtfdc�r any td�e,ttotiUous or <br /> frsudulsnt Riatementi vr re�risronfotiorw or m�lcw w uws ar►y tsla wtitinp a doounNnt k�rowirtp��n'»tn oontai��ny��,fictWou�.w <br /> Truudulcnt�totemuR o�entry,sha114�Tinsd rwt n+oro then 610.000 or Impri�on�d nat mor�th�n fiv�y�r�t,w both. . <br /> +`����\ <br /> SEE ATTAGHMEI��BOUT MDNR PERMIT FEES .r�`�J � 'll, <br /> ThlS�►bm�t7f�01�iS aWlkrbJe kt Gn ;;•^ J�,` �,` �- ''/,.� <br /> � PriAtod On R9CyCled POp� :`` _1 <br /> n, <br /> Gll9/nOtA�910�►mCt UpOn f�qu9S1. Ca+i�oirx 10'1��wc�s �- i��;.,:; ,, , -; <br /> ?�?: ..,. " / <br /> ' rl�.:::'�,,:1 i ' r . <br /> . .. . . . � 1�,��'1 , .,\,�',j ,���'� <br /> r _ l, <br /> ��"L.._' ._'_�^ <br />