1997-01-23_AgendaPacket - Laserfiche WebLink

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INSTRUCTIONS--PLEASE READ CAREFULLY A copy of this form, with copies of all plans, drawings, etc., should be sent to each agency indicated below. Flease chec't the appropriate spaces below to show everywhere you are sending this form. Remember to ke__°p a copy for your records. X LOCAL GOVERNMENT tJNiT (LGU): city, county, or watershed management organization. Specify the LGU to which you are sending the form: Shoreview _~ The local Solt arvD WATER CONSERVATION DISTRICT (SWCD) for the project. Specify the county SWCD: flamsey X WATERSHED DISTRICT (if one exists for the project area). Specify the Watershed District: Grass Lake Water Management Organization `Y MINNESOTA DEPARTMENT OF NATURAL RESOURCES (MONK) regional Office X U.$. ARMY CORPS OF ENGINEERS (CORPS). $end the CORPS Copy t0: Department of the Army, Corps of Engineers, St. Paul District, ATTN: CO-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 (MPCAI. MPCA water quality rules may apply to your proposed project. ATTENTION (FROM USDA1: Any activity including drainage, dredging, filling, leveling or other manipulations, including maintenance, may affect a landuser's eligibility for USDA benefits under the 7985 Food Security Act as amended. Check with your local USDA office to request and complete Form AD-1026 prior to initiating activity.. IMPORTANT: Some agencies, including the Corps of Engineers and the MDNR accept this form as a permit application form. I; ycu 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. YYYYZYYY.....YYYYYYYYYYYYYYY....,.YYYYYYYYYY..YYYYYYYYYYYYYY.... Application is hereby made for a permit or permits to authorize the activities described herein. I certify that I am familiar v,ith the information contained in this application, and that to the best of my knowledge and belief such information is true, complete, and accurate. I further certify that I possess the authority t underake the proposed activities or I am acting as the duly authorized agent of the applicant. ' ^ ~ Signature of Applicant Date Sign, ure f 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 helow is provided. Agent's Name and title: Gregarv A. Mack, Director Agent's address: 2015 North Van Dyke St. MN 55109 A.gent's telephone: ( 612) 777-0393 13 U.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction of any department or agency of The United States knovringly and ~.villfully 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 [o contain any false, fictitious, or fraudulent statement or entry, shall be fined not more than S 10,000 or imprisoned not more than five years, or both. SEE ATTACHMENT ABOUT MDNR PERMIT FEES this information is a~~ailab/e in an C, printed on Recycled Paper alternative fOrmCt Upon reC~UeSt. Ccrlfcin5lCAposfconstrierwcs'e