pf_03308 - Laserfiche WebLink

Home

" -~ ~NSTIFUJJCu~OIi\!lS--!PlLlEA$lE [RlEAIDJ CA[RlE[FQ.JJ1L1L V 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 for your records. LOCAL GOVERNMENT UNIT (LGU): city, county, or watershed management organization. Specify the LGU to which you are sending the form: The local SOIL AND WATER CONSERVATION DISTRICT (SWCD) for the project. Specify the county SWCD: WATERSHED DISTRICT (if one exists for the project area). Specify the Watershed District: MINNESOTA DEPARTMENT OF NATURAllRESOURCES (MDNIR) regional office U.S. ARMY CORPS OF ENGINEERS (CORPS). Send the CORPS copy to: Department of the Army, Corps of Engineers, St. Paul District, ATTN: CQ-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 (FROM USDA): Any activity including drainage, dredging, filling, leveling 01 other manipulations, inc:uding maintenance, may affect a landuser's eligibility for USDA benefits under the 1985 food Secmity Act as amended. Check with your local USDA office to request and complete form AD-1025 prior to initiating activity. IMPORTANT: Some agencies, including the Corps of Engineers and the MDNR accept this form as a permit app!!cation form. If you wish this form to constitute an application to the Corps and/or MDNR for any necessary permits for your project please carefully read the following information and sign where indicated. 1111111111111111111111111111111111111111111111111111111111111111 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 ccurate. I further certify that I possess the authority to undertake the proposed activities or I am acting as the duly authoriz ag:101 the applicant. Signature of A 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 information requested below is provided. Agent's Name and title: Steve Boggs I Midland Hills Country Club I~ager Agent's address: 2001 Fulh~ Street St 0 Paul p MN 55113 Agent's telephone: (651) 631- 1545 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 falsifies. 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. SEIE ATTACHMIEU\lJT A180UT M[OJ~~ !PIE~M~T IFIEES This information is available in an altemative format upon request. ~ Printed on Recycled Paper Contains 10% postconsumar waste