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iVA-0266i0-03B (V.2.02 for MS WORD)9/l7l2007
<br /> Minnesota Local/State/Federal Appficafiion Form for Water/Wetland Projects
<br /> � For Internal Use Only
<br /> Application No. Field Office Code Date Initial Application Received Date initial App6cation Deemed Complete
<br /> PART I: BAS1C APPLICATION a D�O — b�
<br /> "See IlELP"direcis you lo importent additional iaformatioe and assislenee in I�struclioas,Pege 1.
<br /> 1. LANflOWNER/APPLICANT CONTACI'IN�'ORMATION(See Help 1) R E C E 1 V E D
<br /> ���: Gind� S. 6ray Phone: �52: �1 I ' �O� (P
<br /> Complete mailing address: ggp �Jar t e��e ocJ �Ac.d (rp�e� �q,jL�, � tY� 1J 5 s 3 s� DEC 312�09
<br /> lA. AUTHORIZED AGENT{See Hdp!A) (Only lfqpplteable;an r�ent is Ko1 reqWrtd) DNR
<br /> Name�Y}i 11r1�4or1 iCA �rir.►bi C la'toL�i n�honc: �15L- �}7 4-Ci 45 y
<br /> Complete mailing adclress:eJ00 v�e.s+- tA.K.e S-Er--c,�.,+ C.x�e.ls�o� , �N 5S 3c�+-� Waters
<br /> 2. NAME,TYPE A1�ID SIZE OF PUBLIC WATERS or WETLANDS IMPAC['ED(Atlach Additiona!Project A�eQ sheets if nxded)
<br /> Name or 1.D.#of Waters Impacted(if applicable;if known): ps- �!7 -'L 3-y 3 - o0 0 {
<br /> (Check etl that appiy): �Lake ❑River ❑Cinculer 39 Wetland type:� 1,� 1 L,0 2,❑3,❑4,[]5,Q 6,❑7,❑8
<br /> Wetland plant commanity typel: ❑shallow open waier,�deep marsh,❑shallow marsh,❑sedge meadow,❑fresh meadow,
<br /> ❑wet to wet-mesic prairiq[f calcaieous fen,❑open bog or coniPerous bog,❑shrub-cerr/alder thicket,
<br /> ❑herdwood swemp or coniferous swamp,�f]oodplain fotesl,❑seasonally flooded baSin
<br /> Indicate size of eatire lake or welland(check one): ❑I,ess than 10 acres(indicate size: ) ❑ 10 to 40 aeres ❑Greater than 40 acres
<br /> 3. PROJECT LOCATION (Injormation can be found on properly tax stntenzent,property litle or�itle insuroaceJ:
<br /> Project street addr�ss: $$0 �0�+�W�ad Ro�4+l Firc#: City(if applicable): I�°j �A..ILG
<br /> %,Section: Section: Township it: Range#: County: �q�;ri
<br /> Lot#: Biock: Subdivision: Watershed(name or#) CTCM locetion:N E
<br /> Attach a simple site locator map. If nceded,include on the map written direcdons to the site from a known location or landmark,and
<br /> provide dis-tances from known locations, [,abel the sheet SITE LOCATOR A�L4P.
<br /> 4. TYPE OF PROJECT: Describe the type of proposed work. Atiach 7YP�OF PROJECT sheet if needed.
<br /> '+�,iP 2p�
<br /> S. PROJECT PURPOSE,DESCRiPTION AND DIMENSIONS: Describe what you plan to do end why it is needed,how you plan to
<br /> construct the project with dimensions(length,width,depth),erea of impact,and whcn you proposc to construct th�project 7'his is the
<br /> moat important part ofyour application. See HELP 5 before completing this�ectioe;see What To Iuclude on Plans(Instructions,
<br /> page 1), Attach PRQIECT DESCRIPTION sheet.
<br /> Footprint of project: acres or square feet drained,filled or excavated, �S �.1'nt�l ��-'�
<br /> 6. PROJEGT AGTERNATIVES: What altematives to this proposed project have you considered thst would avoid or minimize impacts
<br /> to wetlands or waters? List et least TWO additional altematives to your project in Section S that avoid wetlands(one of which may be"no
<br /> build"or"do nothing"),and explain why you chose to pucsue the option described in this application over these alternatives, Ariach
<br /> PRQJECf ALTERNATIYES sheet if needed.
<br /> 1. AD.IOININC PROPERTY OWNERS: For pmjects thaL impact more than i0,000 square feet of water or weUands,�ist ihe complete
<br /> mailing 8ddresses of adjacent property owners on en atlached separate sheet (See HELP 7)
<br /> �C t� ��a.c.�c.d.
<br /> 8. PORTION OF WORK COMPLETED: Is any portioa of the work in wetlend or water areas already completed? ❑Yes �No. ff
<br /> yes,describe the completed work on a sepaiate sheet of paper labeled WORK ALREADY COMPLETED. (See HELP 8)
<br /> 9, STATUS OF OTHER APPROVALS: List any other permits,reviews or approvals relaled to this proposed project 1ha2 are either pending or
<br /> have already bten approved or denied oo�9ep�nte attscded shect See HELP 9.
<br /> l0. I em applying for atate and loeal authori�sNon to conduct the work described in this applieation. [am familiar with the informalion
<br /> contained in this application. To the best of my knowledge and bclief,all information in Part I is lrue,complete,and accurate. I possess
<br /> the authoriry to undertaka the work describcd,or I am acting as the duly authorized a ent of the applicant
<br /> � � :/ �rl 1 � IZ/
<br /> ��` �. � `'� "'�.,,_. "�I a�c 1 p�i �r li o�
<br /> Signctture�Jopplicant(La�rdowner) �J Dat�� ,$ignature ojagent(ifapp(icable) Dafe
<br /> T6is block must be si�ed by the person who desiies to undertake the proposed ectivity end has Ihe necessary property rights lo do so. If only the Agenl has signed,
<br /> please etfaeh a separate shea signad Ay the landowner,giving necessary aulLorinetioa Lo the AgenL
<br /> �See R'eBmd PlaxRs aqd Ptanr Co�nurniLies ojMiNeuolc and fi'ueoxsln(Egge�a arrd Rrtd,1997J as modi0ed by the Board of Water ud Soil Raources,
<br /> Uoited SMtes Army Corps of Eogineera
<br /> Minnesota L,acaVStatrJFedent Applicarion Forms for WatcdWedand Projects
<br /> Pege I
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