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' .APP~.ICATION FOR DEPARTMENT OF THE ARMY PERMIT (33 CFR 32~ OMB APPROVAL ~~~ I+:~epires Deco `
<br />The public burden for [his collection of information. is estimated to average 10 hours per response, although the majority of applications should require 5 hours or less. This includes
<br />the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information Send
<br />comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducurg this burden, to Deparhnent of Defense, Washington
<br />Headquarters Service Directorate of Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302; and to the OfSce of Management
<br />and Budget, Paperwork Reduction Project (0710-0003), Washington, DC 20503. Respondents should be aware that notwithstanding a~ other provision of law, no person shall be
<br />subject to any penalty for failing to comply with a collection ofinformation if it does not display a currently valid OMB control number. Please DO NOT RETURN your form to
<br />either of these addresses. Completed applications must be submitted to the District engineer having jurisdiction over the location of the proposed activity.
<br />PRIVACY ACT STATEMENT: Authorities: Rivers and Harbors Act, Section 10, 33 USC 403; Clean Water Act, Section 404, 33 USC 1344; Marine Protection, Research and
<br />Sanctuaries Act, 33 USC 1413, Section 103. Principal purpose: Information provided on this form will. be used in evaluating the application for a permit Routine uses: This
<br />information tnay be shared with the Departrnent of Justice and other Federal, state, and local government agencies. Submission of requested information is voluntary; however, if
<br />information is not provided the permit application. cannot be evaluated nor can a permit be issued.
<br />ITEMS 1 THROUGH 4 TO BE FILLED IN BY THE CORPS
<br />1. APPLICATION NO. 12. FIELD OFFICE CODE 13. DATE RECEIVED 14. DATE APPLICATION COMPLETED
<br />YOU DO NOT NEED TO COMPLETE ITEMS 6-10 and 12-25 in the SHADED AREAS.
<br />All applicants must complete non-shaded items 5 and 26. If an agent is used, also complete items 8 anal 11. This optional Federal form is valid
<br />for use only when included as part of this entire state annlication packet.
<br />5. APPLICANT'S NAME ~bf~1 8. AUTHORIZED AGENT'S NAME AND TITLE (an agent is not required)
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<br />b. ~PI'Ltc;~rar'a r,~~izess"`~:~-~~- C:ry3>7: ~.~. ' 9. A~~-T s ~>ss~ l
<br />-7 :~I'P,LiC_hNT SkZaC2~ i10.'' ~ Imo. Ac,ENT'S i'HOhE Nc7
<br />11. STATEMENT OF AUTHORIZATION (if applicable • oo plete only :f authorizing an agent)
<br />I hereby authorize ~ to a on my behalf as my agent in the processing of this application and to furnish, upon request,
<br />supplemental infomtafion in sup o o this pe it ap `ti
<br />APPLICANT"S SIGNATURE: ~`~ ~- DATE: ~•V
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<br />• 12; PROJEf`T NARI[, UR T17'LE (sec irist~ctionsl ~~~2;~~ , }t, F ~ J^ r ,)rl~r t ~7 -
<br />13: t~I,bMc.(~F W=~T~'RBUD1'; IF KN0;4'IV {ifapplicablc) ; 14 PROS`ECT5TIL7=,ET.~DRESS_(tfappiicablc)
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<br />16'OTRER? OCATI(3N DESCRIPTIONS, IF ;<.NtJU~ ;J (,ec instntctioris) , ;';
<br />' 7. DIR~CTIhNS TD TIIE SIT1= L8, •N~T[~RE OF Ar'3'Iti}i~ °? ` '`~ 3 s ;' n ,;
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<br />s? PR9~JF!'T PGRPiiSI' ,,?0. REAfilI;V(Sj rc~R Ells(. h 4Rrf rte;, _ ,
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<br />2t: TYDES t~F At.~TF:RIAL BEINs,,DtSCHARiiEC1.~2JD'11iE A1~IOTJNT CiJ= EACH ~FPIi TN CQBIC,Y'ARI1S ~tr~ ,,;
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<br />^Z:~SI_`RFAGf AREx1)z~ Ai:RES OF `~!Ei LA~1175 i.~R C~TIiER ti'Vr?T.rs1LS FILIEC) ~ 4 z ~ -
<br />23: IR A, tS; s''C3t2T10N,C1FTi1>r tS+gRK ~LREF~U~iLCIt~iPLETE?:YES _ NO TE 1'ES 1~FSCRIBET,C1'v1PtETI<Il'kVORK '
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<br />2~i ADDR~SS~S ()Fr1I}JOIlgINt::I?RpI'LRTY OtiINCRS, '~ s ~s
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<br />'S: L!ST.OF O'~T3~R C1rRt 1FICA~'IONS OR APPROVAI.S/IJF,tJdAi:S RE'.: Ef i~Pd FRgM t~Tkil•;~t"1;EDE[tt1L STt~:~'E OR LrJ.~'~L; Afi)Nt,'ES NUR
<br />~ucJI~1C.QEai',1tlHk g1N Ti-t15 APPLICA'I'IO~v. .) { _~ "'
<br />26. Application is ~a a for a permit or permits to authorize the work described in this application. I certify that the information in this
<br />,application is comp ete ancurate. I further certify that I possess the authority to undertake the work described herein or am acting as the duly
<br />Si tore of app ~ t Date Signature of agent (if any) Date
<br />The application mus stgned y the person who desires to undertake the proposed activity (applicant), or it maybe signed by a duty authorized agent if
<br />the statement in Block l l has been filled out and signed. 18 U.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction of any
<br />department or agency of the United States knowingly and willfully falsifies, conceals, or covers up with any trick, scheme, or disguises a material fact or
<br />makes any false, fictitious or fraudulent statements or representations or makes or uses any false writing or document knowing same to contain an false,
<br />fictitious or fraudulent statements or entry, shall be fined not more than $10,000 or imprisoned not more than five years or both. ~, 's ~ ~ ,.,
<br />ENG FORM 4345, Ju197 EDTITON OF FEB 94 IS OBSOLETE. (Proponent: , ~-b~) O ~
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<br />Minnesota LocaUState/Federal Application Forms for Water/Wetland Projects ~ ~i t~~ GQ~~
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