|
<br />,y,~-oz62aot LOCAL -STATE -FEDERAL WATER RESOURCE PROJECT NOTIFICATION /APPLICATION FORM
<br />Use this form to notify/apply to the U.S. Army Corps of Engineers, the Minnesota Department of Natural Resources, and your Local Government Unit
<br />of a proposed water/wetland project or work which may fall within their jurisdiction. These agencies should advise you of their jurisdiction or permit
<br />requirements within 45 days. Soma LGU's may also require submission of their own application forms. Fill out this form completely and mail a copy,
<br />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
<br />AUTHORIZATIONS BEFORE BEGINNING WORK. /f,,
<br />AGENCY USE ONLY: LGU NUMBER: MDNR NUMBER: l~D "' DU~~ CORPS NUMBER:
<br />I. Applicant's Name (Last, First, M.I.) Authorized Agent, if any Area Code, Telephone
<br />Address (Street, RFD, Box Number, City, State, Zip Codel
<br />II. Location of proposed project (attach drawing showing how to get to site) / - ~~. ~W F L ~~ QSa `~~~j-y- ~
<br />COUNTY QUARTER SECTION(S) SECTIONS(s) No. TOWNSHIP(s) No. RANGE(sl No. Lot, Block, Subdivision
<br />FIRE No., BOX No., OR PROJECT ADDRESS NAME OF WATERBODY AFFECTED and NUMBER (IF KNOWN)
<br />C~.~' ~ 5 S O
<br />III. ESTIMATED PROJECT COST: S ~' ~L~ r ~ ~ LENGTH OF SHORE AFFECTED (in feet): ~../ ~ ~~ f
<br />IV. VOLUME OF FILL OR EXCAVATION (Cubic Yarde): (NOTE.• You may substitute dimensions)
<br />AREA FILLED OR EXCAVATED IS Acres, OR Square Feet
<br />V. TYPE OF WORK AND AREA (CHECK ALL THAT APPLY): ^ ACCESS PATH ^ BRIDGE ^ CULVERT ^ DAM
<br />^ CONSTRUCT ^ GRAIN EXCAVATE ^ DOCK ^ RIPRAP ^ SANDBLANKET
<br />^ FILL ^ REMOVE ^ REPAIR
<br />1~LgKE ^ SHORELINE ^ WATERWAY ^ WETLAND
<br />OTHER (DESCRIBEI: ~ f~~-- L-- ~
<br />WETLAND TYPE(S) AND ACREAGES) PROPOSED TO BE FILLED/DRAINED:
<br />-, _ _ z ~ ~ , ,.,,, ~c~S .,~„ nr,,,r.~, i.,~~,.~!o ~ ;~c~~~otlo~ of env oFooosed rompensatorv mitigation. Imoorrent: Irientifv
<br />any disposal and borrow areas. Describe the work below: how it would be done; what equipment would be used.
<br />VI. PROJECT PURPOSE (why is this project needed--what benefits will it provide?):
<br />~, F_ /~-r a v h /~-/ v c r< 7-e v S ,~ Lr~ /~ ~ Fc 2 D ©c. /~ 1~ s T~ L C ~.Ti o u
<br />~ rt r L u-' ~ i ~`'~
<br />VII. ALTERNATIVES (describe any other sites or methods that could be used to achieve the purpose of your project while avoiding or minimizing
<br />wetland/water impacts: Attach additional sheets, 'if needed).
<br />q ~ ,ate„ ,~+ !.
<br />VIII. GATES: Proposed start of activity: Proposed completion: --" r-~:~ ~ - '
<br />(Identify any completed work on an attached drawing) ` ~~~°tC'^' /,
<br />IX. ADJOINING PROPERTY OWNERS (Attach list if more than two) ..,`v', ,. ~ r~' `'r'
<br />Address City State 4 `. `' =`~
<br />Name ~ ~ n r. 7 F ~ r e= ~ ~ /Z G~ 1..: / / ~-6..h. ~J~/i ~
<br />-,, rc n
<br />~e-
<br />X. PERMITS have been received tenter an R) or already applied for (enter an A) from: ~ R _ ARMY CORPS OF ENGINEERS _ COUNTY
<br />TOWNICITY WATERSHED DISTRICT _ MN POLLUTION CONTROL AGENCY Q9 ~- ,,.~['~
<br />Has an archaeological survey of the project site been done? ~ If so, by whom:
<br />I hereby notify the recipients of this form of the project proposed herein and request that I b® advised of any permits or other determinations concerning
<br />this project that I must obtai I understand that proceeding with work before all requked authorisations are obtained may subject me to Federal, State,
<br />and/or local administrative, c' 17 and/or criminal penalties.
<br />DATE: ~ ~ 3 -
<br />.~
<br />Signs re erson roposing roject or gent
<br />ni trice rnoeetn i v Qcen entn Cr1MP1 FTF ROCK OF FORM> > >
<br />
|