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~! ~ i.,,, C~F;i~:~,,.....,, .`r:,~.liili ,.::~ ~.J~ ~i.~ifi~„ t%, :Ll'.'li L:: C::i ~... ., .J: ?ti~.Jfi ii'1f[:1~ I:.C <br />previous ten years; AND, <br />(iii) the replacement wetland was not restored with financial assistance from public <br />conservation program; AND, <br />(iv) the replacement wetland was not restored using private funds other than those of the <br />landowner unless the funds are paid back with interest to the individual or <br />organization that funded the restoration and the individual or organization notifies the <br />local government unit in writing that the restored wetland may be considered for <br />replacement. <br />(15) Has proof of replacement wetland recording notice been submitted to LGU? <br />Yes ~_ No <br />Special Considerations <br />To the best of the applicant's knowledge, are any of the following factors applicable at the impact or <br />replacement site? Note whether present or not by indicating as follows; Impact Site (I), Replacement <br />site (R), Both (B), Neither (N). <br />(1) federal or state-listed endangered species Yes `~ No <br />(2) rare natural communities Yes ,~ No <br />(3) special fish and wildlife resources including: <br />(a) fish passage and spawning areas Yes ~ No <br />(b) colonial waterbird nesting colonies Yes C3 No <br />(c) migratory waterfowl concentration areas Y-~ No <br />(d) deer wintering areas Yes _~ No <br />(e) wildlife travel corridors Yes _~_ No <br />(4) archaeological or historic sites Yes 8 No <br />(5) ground water sensitive areas Yes ~~ No <br />(6) sensitive surface waters (e.g. DNR designated trout waters) Yes $ No <br />(7) educational or research sites Yes ~ No <br />(8) waste disposal sites Yes ~_ No <br />(9) is the project consistent with local plans (e.g. watershed management plans, land use plans, <br />zoning and master plans.) _ f~ Yes No <br />Replacement Assurance <br />~~1~FT-; C >'i~%,n;Js (Applicant) confirms by signature below that; 1.) the wetland will be <br />replaced before or `oncurr with the actual draining or filling of a wetland OR; 2.) an irrevocable bank <br />letter of credit or other security acceptable to the local government unit to guarantee the successful <br />completion of the wetland value replacement has been provided. <br />Signature <br />I hereby affirm that the information above is correct and truthful to the best of my knowledge. <br />,, <br />-;, ~~~- ~ 7~~,~-~-l-l~~!~rv-w-. <br />(aPPlicaru aigna[uro) (Daft) <br />(witncss/LGU Official sigaaturo) (Date) <br />®: rcp`3pp.f« (BWSR/JI 101.`Cl9'!) <br />3 <br />