1995-04-27_AgendaPacket - Laserfiche WebLink

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y~ -~~~y INSTRUCTIONS--PLEASE READ CAREFULLY 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. X LOCAL GOVERNMENT UNIT (LGU): Clty, county, or watershed management organization. Specify the LGU to which you are sending the form: City of Roseville The IOCaI SOIL AND WATER CONSERVATION DISTRICT (SWCD) for the project. Specify the county SWCD: X WATERSHED DISTRICT (if one exists for the project area). Specify the Watershed District: Grass Lake Watershed Management tZrganization ~_ MINNESOTA DEPARTMENT OF NATURAL RESOURCES (MNDR) feglOnal Office ~_ U. S. ARMY CORPS OF ENGINEERS (ACOE). Send the ALOE Copy t0: Department of the Army, Corps of Engineers, St. Paul District, ATTN: CO-R, 190 Fifth Street East, St. Paul, MN 55101-1638 Ns~: 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 USDAI: Any activity including drainage, dredging, filling, leveling or other manipulations, including maintenance, may effect a land user's eligibility for USDA benefits under the 1985 Food Security Act as amended. Check with your local USDA office to request and complete Form AD-1026 prior to initiating activity. IMPORTANT: Same agencies, including the Corps of Engineers and the MDNR accept this form as a permit application 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. 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 accurate. 1 further certify that I possess the authority to undertake the proposed activities or I am acting as the duly authorized agent of the applicant. fZ°3o-`r'~ ~ Signature of Applicant Date 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: Mr Mark Lobermeier P.E. s Agent's address: Short Elliott Hendrickson Inc. 3535 Vadnais Center Drive, St. Paul, MN 55110 Agent's telephone: 612 490-2028 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. SEE ATTACHMENT ABOUT MDNR PERMIT FEES