1997-01-23_AgendaPacket - Laserfiche WebLink

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INSTRUCTIONS-PLEASE READ CAREFULLY A copy of this forth, witit 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 senddnq tfvs forth. Remember to keep a copy for your records. X LocAy GovstvMr;NT UNrT (LGU1: dty, county, or watarsfxld' management crganizaticn. Specify the LGU to which you are sending the form: 5}>(jR~(1Q1~ X The IOCaI SOa AND WAtst CONSSiVATXJN Dtstwcr (SWCD) for the project. Spedfy the county SWCD: ~MS~ NJA7~tsrlm DlSTR7CT (if one exists for the project area). Spedfy the Watershed District: ~1~55 ~~ ~~X(~IZ-Maar~r~~r d~~t~~~ MINNE30TA DFPAftTMENT oa NATtmAt_ RESOURC>:s (MONRy regional office X U.S. ARMY Cocas of ENC?/E~itS (ACOQ. Send the ACOE copy to: Department of the Army, Corps of Engineers, St. Paul District, ATTN: CO-R, 190 Ffth Street East, S[. Pau(, MN 5 5 7 01-1 638 Note: The above agendes may provide a copy of your completed form to the Minnesota Pollution Control Agency (Mi-CA). MPCA water quality rules may apply to your proposed project. ATTENTION (FROM USDA1: Any activity tnduding drainage. dredging, filling, leveMg Or other tttardpulattorts, tnduding maintenance, may affect a lartduser's a!lpbIItty for USDA benefrts under the 1985 Food Securfry Act as amended. Chock wig your local USDA of:,ce to request and complete Form AD-1026 prior to Irthfatinq activfty. IMPORTANT: Some agendes, indudng the Corps of Enpneers and Lhe MDNR accept this form as a permit application. form. If you wish this farm io constitute an application"to the Corps and/or MONK for any necessary permits for your project please carefully read the following information and sign whue indicated. IIZIZZIIZIIIIZIZZZZZZZZZIIZZZZZZZIIIIZIZZIIIIIZZIIZZZZZZZZIZZIIZ Application is hereby made for a permit or permits to authorize the. activities described herein. 1 crsrpfy that 1 am familiar with the information contained in this application, and that to the best of my knowledge and belief suet information is true, complete, and accurate. I ftuttter certify that 1 possess the atrchority to undertake the proposed acdviries w 1 am acting as ~e duty auL`tcrized agent of the applicant. f 1-3-9~ Signature of Appiicartt Date Sig Hof Agent Date N~ic 4: The appcation mus•, be signed by the person who desires io undertakt the proposed ac;iv'rty (applicant) or it may be signed by a dtiy authorized agent it tfx information requested below is provided. - Agent's Name and title: GI~UVYi ~' ~'~~ ~~~x~g' Agent's address: ZD'S N• VAlJDYKE 5r• MAt~,tooD . MN 5510 Agent's tekphene: (GI L i 7~~ -bag 3 18 U.S.C. Section 1001 pravidea that: Whoawr, in any rrunner within the jurisdicdan of any depertmant or agency of The Urdted Staten knowingly and willfully fdsifiea, eoncada, or eavara up by any trick, scheme, or deviea a materiel fxt or makes arty fdae, fieddoua or fraudulent etatamanta or representedana or makes ar uses any fdae writing or document knowing aacna to eontdn any fdae, fictitinua, or fraudulent atetement or entry, shell be fined hat rtwra than f 10,000 or irtpriaoned not mare then five yeera, or bath. SEE ATTACHMENT ABOUT MDNR PERMIT FEES