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P:"?-026620-03B (V.2.01 for MS WORD) 02/14/03 Minnesota Local/StatelFederal A lication Form for Water/Wetland Pro'ects n!~ ~~~~ For Internal Use Only A~_ca ion o. .Field Office Code Date Initial Application Received Date initial Annfication Deemed Comnlete PART I: BASIf~ APPLICATI®N "See HELP" directs you to important additional information and assistance in Instructions, Page 1. 1. LANDOWNER/APPLICANT CONTACT INFORMATION (See Help 1) ^~^ Name: ~''~`~ G ~ ~ ~? ~'i ~~ Phone: ~jJ- t/~117 ° ~ Z~ d ~/Er~4,ti`c1 ~ ~/L;C~?Y7 C.g ~ lam'{~I~f PC's Complete mailing address: F _ J (~ ~i(7 ~a v 1 <,~ C"~ ir1 ~~1 ~ J: t i~(3~y~' c:; ~ ~~ t VY1lv4 S Sf lA. AUTHORIZED AGENT (See Help IA) (Only if applicable; an agent is not required) Name: t .~ ~ Phone: Complete mailing address: /~~~' 2. NAME, TYPE AND SIZE OF PUBLIC WATERS or WETLANDS IMPACTED (Attach Additional Project Area sheets if needed) Name or LD. # of Waters Impacted (if applicable; if known): Ste, f~-~ ~~~. (Check all. that apply): ^Lake ^River ^Wetland type ^ 1 ^ IL ^ 2 ^ 3 ^4 ^ 5 ^ 6 ^ 7 ^ 8 Indicate size of entire lake or wetland (check one): ^ Less than 10 acres (indicate size: ) ^ 10 to 40 acres ^ Greater than 40 acres 3. PROJECT LOCATION (Information can be f and on property tax statement, property title or title insurance): Project street address: /~ !~' ~~~ ~ Fire #: City (if applicable): I/a Section: Section: Township #: Range #: County: Lot #: Block: Subdivision: Watershed (name or #) Attach a simple site locator map. If needed, include on the map written directions to the site from a known location or landmark, and provide distances from known locations. Label the sheet SITE LOCATOR MAP. 4. TYPE OF PROJECT: Describe the type of proposed work. Attach TYPE OF PROJECT sheet if needed. 5. PROJECT PURPOSE, DESCRIPTION AND DIlI~ENSION5: Describe what you plan to do and why it is needed, how you plan to construct.the project with dimensions (length, width, depth), area of impact, and when you propose to construct the project. This is the most important part of your application. See FIELP 5 before completing this section; see What To Include on Plans (Instructions, page 1). Attach PROJECT DESCRIPTION sheet. ~~~ ~~ Footprint of project: acres or square feet drained, filled or excavated. 6. PROJECT ALTERNATIVES: What alternatives to this proposed project have you considered that would avoid or minimize impacts to wetlands or waters? List at least TWO additional altematives to your project in Section 5 that avoid wetlands (one of which may be "no build" or "do nothing"), and explain why you chose to pursue the option described in this application over these altematives. Attach PROJECT ALTERNATIVES sheet if needed. 7. ADJOINING PROPERTY OWNERS: For projects that impact more than 10,000 square feet of water or wetlands, list the complete mailing addresses of adjacent property owners on an attached separate sheet. (See HELP 7) ~-' f j[~ 1J I7G-•, l:-- 8. PORTYON OF WORK COMPLETED: Is any portion of the work in wetland or water areas akeady completed? ^ Yesy~No. If yes, describe the completed work on a separate sheet of paper labeled WORK ALREADY COMPLETED. (See HELP 8) 9. STATUS OF OTHER APPROVALS: List any other permits, reviews or approvals related to this proposed project that are either pending or have already been approved or denied on a separate attached sheet. See HELP 9. / _ 10. I am applying fo sat and local authorization to conduct the work described in this application. I am familiaz with the information c tained in this appl catio To the best of my knowledge and belief, all information in Part I is true, complete, and accurate. I possess e ority to un -the work described, or I am acting as the duly authorized agent of the applicant. U . ~~ Signature of app.ican tzn weer) Date Signature of agent (f applicable) Date- ~2 ~ ~ S ~^ .~ This block must be signed by the person who desires to undertake the proposed activity and has the necessary property rights to do so. L only gent has d, please attach a separate sheet signed by the landowner, giving necessary authorization. to the Agent. ti ~~ Z _a ~~ ~~~~ Minnesota LocaUState/Federa] Application Forms for Water/Wetland Projects ~ 17MzrY, ,~ ~ Page I .tom, ~`~'~