2001-08-23_AgendaPacket - Laserfiche WebLink

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~Z620-J1 LOCAL -STATE -FEDERAL WATCR RESCURCi PROJECT NOTIF1CATiCN / APpLfCAT10N FORM e [his form to notify/apply to the U.S. Army Corps of Engineers, the Minnesota Department of Natural Resources, and your Local Government Unit f a proposed ~._ater/wetland project or work which may fall within their jurisdiction. These agencies shculd advise you of their jurisdicticn or permit requirements within 45 days. Some LGU's may also require submission of their own application forms. F iif 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. YCU MUST 08TAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. AGENCY USE ONLY:. LGU NUMBER: MDNR NUMSER-p~~~~~/~~~~ CORPS NUMBER: I. Applicant's Name (Last, First, M.I.1 Authorized Agent, if any Area Code, Telephone ~~TE~E.~t 0(" ~ ~~sE So~t.tk(~-~(~x~soN ~~~'tetc-~ (b51) ~1F~~- I~k~ Address (Street, RFD, Box Number, City, State, Zip Code1 ~~ I ~ R1C~ S"~R-E~~ ~0`~ V l~.-t.E 1~'((~ S S ~ f ~ - ~Ogj 1 I(. Location of proposed project (attach drawing showing how to get to site) pp ~~ ~ " ~ vA~ltl1~ h,tTj•}IIJ [~t~~E L-kN COUNTY QUARTER SECTION(S) SECTIONS(s) No. TOWNSi-iIP(s) No. RANGE(s} No. ~~ Lot, Block, Subdivision FIRE No., BOX No., OR PROJECT ADDRESS NAME OF WATER80DY AFFECTED and NUMBER (IF KNOWN} vA,~'~~ /''~ iii. ESTIiviATED PRCJECT COST: $ vpp I~C~ LEi`:GTH OF SriCRE AF FcCTED (in, fceti: v~'~C~ IV. VOWME OF FILL OR EXCAVATION (Cubic Yards): (NOTE.• You may substitute dimensions) AREA FILLED OR EXCAVATED IS Acres, OR' Square Feet v~~,~eJ V. TYPE OF WORK AND AREA (CHECK ALL THAT APPLYJ: ^ ACCESS PATH' ^ BRIDGE Q CUWEftT ^ Dann ^ CONSTRUCT ^ DRAIN ^ EXCAVATE ^ DOCK ^ RIPRAP ^ SANOBLaNICET ^ FILL ^ REMOVE REPAIR ^ LAKE I~SHORELINE WATERWAY ^ WETLAND OTHER (DESCRIBE): WETLAND TYPE(S) AND ACREAGES) PROPOSED TO BE FILLEDIDRAINED: Attach applicable drawings, plans, and ASCS crop photos. Include a description of any proposed compensatory mitigation. Important: Identify any disposal and borrow areas. Describe the work below: how it would. be done; what equipment would be used. VI. PROJECT PURPOSE (why is this project needed--what benefits will it provide?): VL. ALTERNATIVES (describe any other sites or methods that could be used to achieve the purpose of yourproj c~xiJe~"i~'otdtng o2iminimizing wetlandiwater impacts: Attach additional(~sheets, if needed). ~ ..I S~~- ~'T'~~Ct'~E~ S~T ~-T ~d~~s 11 '~, ~~. VIII. DATES: Proposed start of activity: Proposed completion: VAtZ,1~~j OrtGO~t-tG~ ~ ~ ~~~ (Identify any completed work on an attached drawing) IX. ADJOINING PROPERTY OWNERS (Attach list if more than two) Name Address City State Zip X: PERMITS have been received (enter an R) or already applied for (enter an A) from: _ DNR ARMY CORPS .OF ENGINEERS _ CouNTY TOWN/CITY _ WATERSHED DISTRICT _ MN POLLUTION CONTROL. AGENCY Has an archaeological survey of the project site been done? If so, by whom: f I hereby notify the recipients of this form. of the project proposed herein and request that I be advised of any permits or other determinations concarninc this project that I must obtain. I understand that proceeding with work before all required authorizations are obtained may subject me to Federal, State, and/or local administrative, civl and/or criminal penalties. of Person Proposing Project or Agent DAT ®~°f/ _ < G < PLEASE CAREFULLY READ AND COMPLETE BACK OF FORM> > >