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NA-r)2h:J1~01 LOCAL -STATE -FEDERAL WATER RESOURCE PROJECT NOTIFICATION /APPLICATION FORM Use this form to notifyiapply to the U.S. Army Corps of Engineers, the Minnesota Department of Natural Resources, and your Local Government Unit of a proposed water/wetland protect or work which may tall within their jurisdiction. These agencies should advise you of their jurisdiction or permit requirements within 45 days. Some LGU's may also require submission of their own application forms. Fill out this form completely and mail a copy, with plans, maps, etc. to each of the agencies listed on the reverse of the form. Keep a copy for your records. YOU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. AGENCY USE ONLY: LGU NUMBER: MDNR NUMBER: CORPS NUMBER: i 1. Applicant's Name (Last, First, M.Lt Authorized Agent, if any Area Code, Telephone Address (Street, RFD, Bux Number, City, State, Zip Code1 II. Locauon~~rr,~ose~prolect (attach drawir~ showlr~ how to get to arts! /f _~ . ,r , ®_,~ ,~, COU TY QUARTER SECTIONisI SECTIONS(s) No. TOWNSHIPLs! No. RANGE(s) No. Lot, Block, Subdivision FIRE No., BOX No., OR PROJECT ADDRESS N~ OF WATERBODY AFFECTED and NUMBER (IF KNOWN) - __ --- 111. ESTIMATED PROJECT COST: S LENGTH OF SHORE AFFECTED (in feet!: IV. VOLUME OF FILL OR EXCAVATION (Cubic Yards): (/VOTE.' You may substitute dimensions! AREA FILLED OR EXCAVATED IS Acres, OR Square Feet V. TYPE OF WORK AND AREA (CHECK ALL THAT APPLY/: 1~,CONSTRUCT ^ DRAIN EXCAVATE FILL ^ REMOVE ^ R PAIR ACCESS PATH ^ BRIDGE ^ CULVERT ^ DAht I~DOCK ^ RIPRAP ~SANDBLANKET LAKE SHORELINE ^ WATERWAY ^ WETLAND OTHER (DESCRIBE/: ~ _,i.l.® ~_~~~.~ , WETLAND TYPEISI AND ACREAGE(S- PROPOSED TO BE FILLED/DRAINED:_~~l~{~ ®~-~ ny.~ ~; ~~ Attach applicable drawings, plans, and ASCS crop photos. Include a description of any proposed compensatory mitigation. Important: Identify an disposal and borrow areas~escribe the work below: how it would be done; what equi nt ould be used. ~ ~~ ~ ~ e~ ~ ~~ `~.~i ~~ ~~ ~{-~a,,~-8. vvi'~- ~-lam., VI. PROJECT PURPOSE (why is this project needed--what benefits vyill it provide!!: (~~ 7'!~C ~~ir ~. ~ ~a ~. c.r ill a ~- P T®d~ >fl,~ ~® a ® L~ .5 C 1 (1U~4.g.~ i4~+.~ ®BC)C Uv~LL-141 ~. ~ l~ ,UITprC~~ ._~c AJt~ ~C.1~asLC~'- VII. ALTERNATIVES /describe any other sites or methods that could~e used to achieve the purpose of your project while avoi Ing or minimizing wetland/water impacts: Attach additional sheets, if neededi. .t. ~~ i~d~> ~!~®tiJ ~'~! ~ J4L.~~G~ a.3 ~'~ !! ~ /~ G 1 ~t~ ®~ dJD'd~.. X. PERMITS have been received (enter an R) or already applied for tenter an A! from: _ DNR _ ARRAY CORPS DF ENGINEERS _ COUNTY _ TOWN/CITY WATERSHED DISTRICT _ MN POLLUTION CONTROL AGENCY Has an archaeological survey of the project site been done? If so, by Whom: 1 hereby notify the recipients of this form of rho project proposed herein and raq t that I b® adv~ed of any permits or o determinations concerning this project that 1 must obtain. 1 understand that proc in» With Work before all requ~ed authrxiaatrons are obtained may subject me to Fitderal, State, andldr local administrative, civ~ And/or criminal penalties. -( ® DATE: Pro or Agent < < < PLEASE CAREFULLY READ AND COMPLETE BACK OF FORM > > >