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1NSTRUCTIONS-PLEASE READ CAREFULLY A copy of this form,with copies of all plans,drawings,etc... may need to be s�t to an ag�cy indicated below...Please check the appropriate spaces below to show everywlrere you are s�ding this form Remember to keep a copy for yourrecords. � MINNESOTA POLLLTTION CONTROL AGEIVCY(MPCA)for NPDES phase II permit --. - _ _ - _ _ _ _- --- - _- - - - - - -- --- -- _ _ ____- -- -. ._ - - - - _ - - _ - 0 The LOCAL GOVERNMENTAL iJNIT(LGU), aty,county or water management organization �MINNESOTA DEPARTMENT OF NAT'LTRAL RESOURCES(MDNR)Regional Office � US ARMY CORPS OF ENGINEERS(ACOE)at Dept.ofthe Army,Corps of Engineers,St.Paul District ATTN:CQ-R, 190 Fifth St.East,St.Paul,MN 55101-1638 Note:The above Agencies may provide a copy of your completed form to the Minnesota Pollution Control Age�cy(MPCA). MPCA water quality requirements may apply to your proposed projec�t. ATTENTION Gfrom USDAI:Any activity including drainage,dredging,filling,leveling or other manipulations,including mainteaiance,may affect a land user's eligibility for USDA b�efits under the 1985 Food Security Act as am�ded. Check with your local USDA office to request and complete Form AD-1026 prior to initiating activity. Application is hereby made for a permit to authonze the activities described herein.I certify that I am familiar with MCWD Rules and that the proposed activity will be conducted in compliance with these Rutes. I am familiaz with tiie information contained in this application and,to the best of my knowledge and belie�a11 information is true,cornplete and accurate. I further certify that I possess the authority to undertake ti�e proposed activity or I am acting as the duly authorized agent of the applicant. � 5� `�,� � � Signature of Apl ' ant(Property Owner} Date Signature of Ag Date NOTE:The application must be signed by the property owner where the propos�i activity is to occur.The application may be signed by a duly authorize�i agent if a letter bearing the original signature of the properiy owner is submitted staring that the agent noted in the pernvt application is the authorized agent of the landowner for all matters relating to the permit.Please provide authonzed agent information below: Ag�t's Name&Title: �dl?�9S j�3,�'/�jtip - ��,�f'� 7S;�L'�f( ,L�JL1+�/��, Ag�t°S Ada��s: 20`73 ��7�6� �L-v°� (.v e "�1'1/�lb L��' t, �� SJ�' � Agea�t's Telephone: �Z �7�- �7� 18 U.S.C.Seciion 1001 provides thai:Whoever,in any manner within jurisdiction of any departm�t or ag�cy of the United States knowingly and willfully falsifies,conceals or covers up by arry trick,scheme,or device A material fact or makes any false,fictitious or fraudulent statements or representations or makes or uses any false writing documart lrnowing same to contain any false,fictitious,or fraudul�t statement or entry,shall be fined not more than$10,000 or imprisoned not more than five years,or both. Page 2 of 2