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APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT (33 CFR 325) OMB APPROVAL NO. 0710-003 Expires Dec 31, 2004
<br />The public burden for this collection of information is estimated to average 10 hour per response,. although the majority of applications should require 5 hours or less. This includes
<br />the time for reviewing inswctions, 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 reducing this burden, to Department 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 Office of Management
<br />and Budget. Paperwork Reduction Project (0710-0003), Washington, DC 20503. Respondents should be aware that notwithstanding any other provision of law, no person shall be
<br />subject to any penalty for failing to comply with a collection of information 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 AcC 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 evacuating the application for a permit Routine uses: This
<br />information may be shared with the Department 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. ~ 2. FIELD OFFICE CODE 1 3. DATE RECENED 1 4. 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 and 11. This optional Federal form is val
<br />for use only when included as part of this entire state application packet.
<br />5. APPLICANT'S NAME ~ 8. AUTHORIZED AGENT'S NAME AND TITLE (an agent is not required)
<br />City of Roseville, Debra Bloom Kelly Bettendorf, Associate
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<br />11. STATEMENT OF AUTHO ATION (if applic e; compl~te only if authorizing an agent)
<br />I hereby authorize Kelly Bettend to act on my behalf as my agent in the processing of this application and to famish, upon
<br />request,. supplemental information i s of this a 'cation.
<br />APPLICANTS SIGNATURE: t DATE: Z (s Q~
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<br />.Application is her y made or a permit or permits to authorize the work described in this application. I certify that the information in chi:
<br />ap ication is complete ac ate. I further certify that I possess the authority to undertake the work described herein or am acting as the dt
<br />~auth zed agent f t e ~ ant.
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<br />Si r o applica Date Signature of ent (if any) Date
<br />The application must si he person who desires to undertake the proposed activity (applicant), or it may be signed by a duly authorized agent if
<br />the statement in Block I 1 has been filled. out and signed. 1$ 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 any false,
<br />fictitious or fraudulent statements or entry, shall be fined not more than $ ] 0,000 or imprisoned not more than five years or both.
<br />ENG FORM 4345, Jul 97 EDITION OF FEB 94 IS OBSOLETE. (Proponent: CECW-OR)
<br />Minnesota LocaUState/Federal Application Forms for Water/Wetland Projects
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