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Project Name and/or Number: 2017-299 <br /> PART FOUR: Aquatic Resource Impact1 Summary <br /> If your proposed project involves a direct or indirect impact to an aquatic resource (wetland, lake, tributary, etc.) identify each <br /> impact in the table below. Include all anticipated impacts, including those expected to be temporary. Attach an overhead view <br /> map, aerial photo, and/or drawing showing all of the aquatic resources in the project area and the location(s) of the proposed <br /> impacts.Label each aquatic resource on the map with a reference number or letter and identify the impacts in the following table. <br /> Type of Impact Duration of County,Major <br /> Aquatic Resource Aquatic Existing Plant <br /> (fill,excavate, Impact Overall Size of Watershed#, <br /> ID(as noted on Resource Type drain,or Permanent(P) Size of Impact' Aquatic Community and Bank <br /> (wetland,lake, Type(s)in <br /> overhead view) remove or Temporary Resource 3 Service Area# <br /> tributary etc.) vegetation) (T)1 Impact Area` of Impact Areas <br /> 'If impacts are temporary;enter the duration of the impacts in days next to the"T". For example,a project with a temporary access fill that <br /> would be removed after 220 days would be entered"T(220)". <br /> 'Impacts less than 0.01 acre should be reported in square feet. Impacts 0.01 acre or greater should be reported as acres and rounded to the <br /> nearest 0.01 acre. Tributary impacts must be reported in linear feet of impact and an area of impact by indicating first the linear feet of impact <br /> along the flowline of the stream followed by the area impact in parentheses). For example,a project that impacts S0 feet of a stream that is 6 <br /> feet wide would be reported as 50 ft(300 square feet). <br /> 'This is generally only applicable if you are applying for a de minimis exemption under MN Rules 8420.0420 Subp.8,otherwise enter"N/A". <br /> `Use Wetland Plants and Plant Community Types of Minnesota and Wisconsin 3"Ed.as modified in MN Rules 8420.0405 Subp.2. <br /> 'Refer to Major Watershed and Bank Service Area maps in MN Rules 8420.0522 Subp.7. <br /> If any of the above identified impacts have already occurred,identify which impacts they are and the circumstances associated <br /> with each: <br /> PART FIVE: Applicant Signature <br /> Check here if you are requesting a pre-aoolication consultation with the Corps and LGU based on the information you have <br /> provided. Regulatory entities will not initiate a formal application review if this box is checked. <br /> By signature below,I attest that the information in this application is complete and accurate. I further attest that I possess the <br /> authority to undertake the work described herein. <br /> Signature: Date: <br /> I hereby authorize Wayne Jacobson to act on my behalf as my agent in the processing of this application and to furnish,upon <br /> request,supplemental information in support of this application. <br /> 1 The term"impact"as used in this joint application form is a generic term used for disclosure <br /> purposes to identify activities that may require approval from one or more regulatory <br /> agencies. For purposes of this form it is not meant to indicate whether or not those activities <br /> may require mitigation/replacement. <br /> Minnesota Interagency Water Resource Application Form February 2014 Page 4 of 11 <br />