2001-08-23_AgendaPacket - Laserfiche WebLink

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, -< J.: ~~~ )NST'r3UC7'10NS--RLEASE READ CARE=iJLLY A copy of this form, with copies of all plans, drawings, etc., should be sent to each agency indicated below. Please check the appropr,ate spaces below to show everywhere you are sending this farm. Remember to. keep a copy for your records. LOCAL CaOVERNMENT UNIT (LGU): City, county, ar watershed management organization. Specify the LGU to which you are sending the form: The IOCaI SOIL AND WATER CONSERVATION DISTRICT (SWCD) fo!' the project. Specify the county SWCD: WAT~s1~r=n DISTRrcT (if one exists for the project area). Specify the Watershed District: MINNESOTA DEPARTMENT OF NATURAL RESOURCES (NIilNR} regional office U.S. ARMY CORPS OF ENGINEERS (CORPS). Send the CORPS Copy to: Department of the Army, Corps of Engineers, St. Paul District, ATTN: CO-R, 190 Fifth Street East, St. Paul, MN 55 1 01-1 638 Note: The above agencies may provide a copy of your completed form to the Minnesota Pollution Control Agency. (MPCA). MPCA water quality rules may apply to your proposed project. ATTENTION (FROM USDA): Any activity including drainage, dredging, fitting, leveling or other manipulations, including maintenance, may affect a landuser's eligibility for USDA benefits under the 1985 Food. Security Act as amended. Check with your local USDA office to request and complete Form AD-1026 prior to initiating activity. IMPORTANT: Some agencies, including the Corps of Engineers and the MDNR accept this form as a permit application form. If you wish this form to constitute an application to the Corps and/or MDNR for any necessary permits for your project please carefully read the following information and sign where indicated. :Y%°.Y$YYYZ%ZY%%YY°Z$ZYYZYe°Z$Z°.ZZZZ:Y~YZ..~ZZYYe~°.YZYZYZ%Y°.%ZZY°.Z Application is hereby made for a permit or permits to authorize the activities described herein. I certify that I am familiar with the information contained in this application, and that to the best of my knowledge and belief such information is true, complete, and accurate. 1 further certify that I possess the authority to undertake the proposed activities or 1 am acting as the duly authorized agent of the applicant. Sig - o App icant Date Signature of Agent Date Note: The application must. be signed by the person who desires to undertake the proposed activity (applicant) or it may be signed by a duly authorized agent if the. information requested below is provided. Agent's Name and title Agent's address: Agent's telephone: 18 U.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction of any department or agency of The United States knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material tact or makes any false, fictitious ar fraudulent statements or representations or makes or uses any false writing or document knowing same. to contain any false, fictitious, or fraudulent statement or entry, shalt be fined not more than $10,000 or imprisoned not more than five years, or both. SEE ATTACHMENT ABOUT MDNR PERMtT FEES This information is avai/Gb1e in Gri prinfied cn Recyc;ed Paper atternGtive format upon request. Contcins 10`~Fostcansurr~rwaste