|
APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT (33 CFR 325) OMB APPROVAL N0.0710-003 Expires Dec 31, 2004 #_
<br />The public burden for this collection of information is estimated to average 10 hours per response, although the maJonty of apphcanons should require S hours or Jess This tacludes
<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 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 maybe 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 ermit a lication cannot be evaluated nor can a ermit be issued.
<br />ITEMS 1 THROUGH 4 TO BE FILLED IN BY THE CORPS
<br />1. APPLICATION NO. C 2. FIELD OFFICE CODE 13. DATE RECENED 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 l 1. This optional Federal form is valid
<br />for use only when included as art of this entire state ap lication acket.
<br />5. APPLICANT'S NAME 8. AUTHORIZED AGENT'S NAME AND TITLE (an agent is not required)
<br />Ramsey County Department of Public Works
<br />- -- -
<br />_ _ _ - -- -1
<br />,I'I'L~t ~,I'IU~\f-.Att ~~U~ 't(iFi;A1'~III~ 't.`t~.
<br />11. STATEMENT OF AUTHORIZATION (if applicable; complete only if authorizing an agent)
<br />I hereby authorize to act on my behalf as my agent in the processing of this application and to furnish, upon request,
<br />supplemental information in support of this permit application.
<br />e vni i(' 4 NT''S RTf;N AT'f JR E:
<br />DATE:
<br />!_'_ I'la~lltl'~;:.~1LUR I]ICL'(s~~ .nsln~~cfi m-7 ~ _
<br />~' I ~_ A.~iUL~t~A~", L,..;O1)l, If' h~~ ',`~A nl.ippli:_;tl~`.i _ ~l I l'ROJC( CJ[i'-L ~al~l~f (/<<~ it~il ~Iti!tbi~ -- -
<br />[LL
<br />1 ~ l (?(-.1 CN 1Vt~i~ I K(i.1C~'T'
<br />Its (~)i~llii~l.Ut'VIltltilJl-.4t'Ril~ilt:1S,1Fh~tt`.~Nr ~~ein'siru~u:~sl
<br />1. I)IKI'111t1h.` 1l_i IlLt.til'1'L ~ ~i,.~.ALU? l)I'i.l,li\ 1!l'
<br />[`~ 1'i~(JIL(T1'i'r~i~);!~ t).iZC.t,(~iti(~ Ci~t:I~ltit_1t16~rG"
<br />-~
<br />____
<br />_1. I"Y~[; 5 tT`~,l , CCGIf~E, LI'I`:U_I~ISC ECfiK~;I'ir~,t~~> CFr!? ~.~ICJt YL t ~FP~'t[ H "II~PL IV t'T'I;IC.I ,',:a?ti _
<br />til~'~1Z1 .,CI'.:~:[.f . !`! ,~( ;([;Si4)h `A1 l l i~~ll~(JI~ t tllil R S~' V"l l 1:~ t tl [ E77
<br />i.ti:-~~1~i~~iii~,ivtit,l-~~u-~~,~>i~h '~I,i<I.tI,~~_~u^lhl_;~1~. ~~rs_ ~:~, T[-:~~,.i~~-i~ ~ I_i-t~:It~~,lh~~~ttt~«~i~t~h.
<br />'i.,'~IiURLti;LSOh:~.1)JC,Itii\GI'1'.tel'Gft'Cl t~~~,G~;~?.,
<br />ILS'I't~rt)Ti~~l,tsL~ll (~~'~Tl(ti`.ti(%1:=~P1'IZI~t~ aL,l)FBI,L`,~IbCL.i~'ri't~itOtt(tIIIP.I?tEh}P:`.f. ~I'~IFIII,L(J(~ 1-3t~G1(Ii~SFI)K
<br />\~tt12I~1~F1('L1iih,{tlV:tlllti.'tii'1'1.7( ',IlOti.
<br />26. Application is hereby made for a permit or permits to authorize the work described in this application. I certify that [he information in this
<br />application is complete and accurate. I further certify [hat I possess the authority to undertake the work described herein or am acting as the duly
<br />authorized agent of th~ licant.
<br />Signature o ap cant Date Signature of agent (if any} Date
<br />The application must. be signed by the person who desires to undertake the proposed activity (applicant), or itmay be signed by a duly authorized agent if
<br />the statement in Block 11 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 ar
<br />makes any false, fictitious or fmudulent 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 $10,000 or imprisoned not more than five years or both.
<br />ENG FORM 4345, Jul 97 EDITION OF FEB 941S OBSOLETE. (Proponent: CECW-OR}
<br />Minnesota LocaUState/Federal Application Forms for Water/Wetland Projects
<br />Page 2
<br />
|