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NA-02622-03 <br />RV q2 's5 PERMIT APPLICATION <br />• OF TO WORK IN PROTECTED WATERS OR WETLANDS <br />I,,DEPARTMENT <br />t �l[ C>'IC% (INCLUDING DAM SAFMI <br />NATURAL RESOURCES <br />► ► Please read instructions before atlemptinq to complete this application. <br />OFFICE USE ONLY. <br />P.A. NO. <br />F__1 SWCD O G/C <br />❑ W.D. ❑ USCOE - <br />Appllicants Name (Last, First, M.I.) <br />Authorized Agent (it applicable) <br />Telephone Number&areacode <br />Address (Street, RFD, Box, Number, City, State, Zip Code) <br />Alt <br />LOCATION OF PROPOSED PROJECT (BE SURE TO INCLUDE SKETCH SHOWING HOW TO GET TO THE SITE) <br />Government Lot(s) <br />Quarter Section(s) <br />Section( <br />o. <br />Township(s) No. <br />Rang, (s No. <br />ot, Block, Subdivision <br />411 <br />Fire No., Box No. or Project Address lco my <br />Project will affect IT Lake. ❑ Wetland or ❑ Watercourse <br />(namef <br />& number. <br />TYPE OF WORK:PROPOSED (CHECK ONE) <br />IV. TYPE; OF PROJECT CHECK ONE) <br />excavate ❑ repair <br />❑,rshoreline El shore -protection ❑ obstruction ❑ dam' <br />C� fill : ❑ remove <br />Do channel ❑ harbor ❑ bridge ❑ other <br />❑ drain ❑ abandon <br />❑ sand blanket ❑ permanent dock C1 culvert (specify) <br />construct ❑ other (specify) <br />Elriprap ❑ wharf <br />O. install <br />ESTIMATED PROJECT COST $ = <br />VI. LENGTH OF SHORELINE AFFECTED (IN FEET): <br />VOLUME OF MATERIAL FILLED OR !EXCAVATED (IN CUBIC YARDS) <br />BRIEF EXPLANATION OF PROJECT: (EXPLAIN WHAT PROJECT CONSISTS OF AND HOW WORK WILL; BE DONE) <br />. <br />? f u,.t i ...Fw„• _,il,^-.^f.v�x.s ...'k::1 •t7i ,.... ..,,,T r, i•'.t.Y„^ � .. :. ..-.S...A'' ^ 1 ; �' ;G' �, +,. {. i:a' ,{ ,#`" .. <br />} <br />PURPOSE OF: PROJECT: (Explain �Lhj this project is needed) <br />ENVIRONMENTAL IMPACT (Anticipated changes to the water and related land resources, including unavoidable but detrimental effects) <br />N x,�AT IVES (Other alternatives to the action proposed) <br />I hereby -make application pursuant to Minnesota Statutes cnapter 1UbAZ ana an supporting rules Tor a permn To worK in or aneoi lilt; auwc llalllVU NIU«k«U <br />waters) in accordance with all supporting maps, plans, and other information submitted with this application. The information submitted and statements made <br />concerning this application are true and correct to the best of my knowledge: <br />STATE OF t- F A , <br />COUNTY OF <br />Subscribed and sworn to before me this <br />Signature of Owner or Authorized Agent <br />Date <br />. tt <br />; f" <br />d <br />!�.•'. .4 �,��{ �� �'r yr; <br />;� ,t i�. J' <br />Signature"ot1'iaee1,) <br />Dale,;: 4 <br />r.�^ <br />;p�istribution: <br />day of',' �.s 1� j <br />197_ <br />" <br />DOUGLAs w. stizoN� <br />White: GNR <br />� NOTARY PUBLIC-MINNESOTi� <br />Blue:,SWCD <br />My corn ion expires <br />"' <br />_ <br />{ <br />.rt r <br />..• ANOKA COUNT <br />.MY COMMISSION EXPIRES NOVEMBER 12y 1994 <br />Green;:Watershed Distract <br />, <br />Goldenrod Clty, or County ; <br />:.Sign re or Notary ; <br />r <br />x".VwVVwwvIt <br />Pink•. Army Corps of Engineers <br />Cana . A licant ` <br />rY' PA <br />:yY <br />