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10/12/07 FRI 10:49 FAQ 952 345 8721 ADMIN NA-026620-03B [t7~. 004 (V.2.02 for MS WORD) 09/01 /04 Minnesota Local/State/Federal A lication Form for Water/Wetland Pro~ects For Internal Use Only ` A lication No. Field Office Code Date Initial A lication Received Date initial Application Deemed Camniete PART I: BASIC APPLICATION "See HELP" directs you to importaneadditional lnformaton and assistance in Instructions, Page 1. 1, LANDOWNER/APPLICANT CONTACT INFORMATION (See Help I) Name: (/V~{l_l.,f~(-(J +uCCGj-I-! Phone: fOIZ ~OS ~~JZ [~ Complete mailing address: tA~t--~ F'~nl~~ ~ ~ t ~. f-~ro ~'~/ ~VJ Y~'~ ~ SS i `2-~ 1 A. AUTHORIZEb AGENT (See Help 1A) (Only if applicable; an agent is not requirrd) Name: Complete mailing address: Phone: Z. NAME, TYPE AND SIZE OF PUBLIC WATERS or WETLANDS IMPACTED (Attach.9dditional Project Area sheets if needed) Name or T.D. # of Waters Impacted (if applicable; if known.): (Check all that apply): ~.ake ^River ^Wetland type ^ I ^ 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 (htforntutton can be found on propet7}~ tax statement, property title or title insurance): Project street address: (p,`~+-~ ~'~ (~'~f1~/ q!0 Fire #~ City (if applicable): ~,~-l-p~~~ '/< Section: dlf C Section: ~ ~ Township #: ~ c ~' 23- Lange #:O ~ Coun 4~~3 ty~ I~-~YYIC~ Lot #: Block: Subdivisimt: Watershed (name or #) {py-73 P UTM location: N E Attach a simple site locator map. If needed, include on the map vrritten directions to the site from a known location or landmazk, and provide distances from. known locations. Label the sheet SITE LOCATOR MAP. 4. 'T'YPE OF PROJECT: Describe the type of proposed work. Attach TYPE OF PROJECT sheet if needed. 5. PROJECT PURPOSE, DESCRIPTION AND DIMENSIONS: 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 lnopose to construct. the project. This is the most important part of your application. See HELP 5 before completing this section; see Whnt To Inc[utle on Plans (Instructions, page 1}. Attach PROJECT DESCRIPTION sheet. ~Plf~c,E C~i~'I7t~s ~o I::T t.~C., i`~~LP--~prY~ Tl~ ~-~P~ryl~~-- WRU~ W [ TYt jJovJ So F~ wt~ is t3o I..~R- t>a ~t~t._-- Footprittt of project: acres or ~ square feet drained, filled or excavated 6. PROJECT ALTERNATIVE5; What alternatives to this proposed project have you considered that would avoid or minimize impacts to wetlands or waters? List at least TW0 additional altetna[ivcs to your project in Section ti 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 alternatives. Attach PROJECT ALTERNATIVES sheet if needed. ~ t~P~~ Ejc l l-~IitJt~ t~ +-ear-n ~ ~ w/~rt.t~ ©~i..fl 1-~ Ro~it-J lr, Ur`1sT~ each,-~tJ(~ ~,,.~n-t-L ~,~ll~c~t rJcv~1 ~innrb~ 7. ADJOINING PROPERTY OV4'NERS: For projects that impact more than 10,000 square feet ofwateror wetlands, hst the complete mailing addresses of adjacent property owners on an attached separate sheet. {See HELP 7a ~/~ 8. PORTION OF WORK COMPLETED: Is any portion of the work in wetland or water areas already completed? ~. Yes ^No. If yes, describe the completed work on a separate sheet ofpaper labeled. WORK ALREADY COMPLETED. (See EIELP 8) 9. STATUS OF OTHER APPROVALS: List any other permits, reviews ar 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 for state and local authorization to conduct the work described in this application. I am familiar with the information co tained in this application. To the best of my knowledge aril belief, all information in Part I is true, complete, and accurate. I possess th authority to under the work described, or I am acting as the duly authorized agent of the applicant. Id~I~ ~O'7 Sigtature of ap i nt (Landowner) Date Signature of agent (tf applicable) Date This block must be signed by the person who desires to undertake the proposed activity and has the necessary propetty rights to do so. If only the Agen~ ig please attach a separate sheet signed by the landowner, giving necessary authorisation to the Agent. Minnesota Lacal/State/Federal Application Forms for Wntcr/Wetlond Projects Page 1 QC~ 12 ZaO~ ~N~ Wat~ra