|
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 mformatton 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 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 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 />informatimi 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 />i. APPLICATION NO. 12. FIELD OFFICE CODE f 3. DATE RECEIVED 14. DATE APPLICATION COMPLETED
<br />YOU DO NOT NEED TO COMPLETE ITEMS 6-10 and 12-25 in the SHADED AREAS..
<br />AIZ 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 valid
<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 />Ramsey County Public Works -Terry Noonan
<br />6. APPLICAN"I"S ADDRESS 9. AGEN"f'S ADDRESS
<br />7: APPLICANT'S PHONE NO. I0. AGENT'S PHONE NO.
<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 />APPLICANT"S SIGNATURE:
<br />DATE:
<br />12: PROJECT NAME OR TI'T'LE (seeinstructions)
<br />13.NAMEOF WATERBODY, TF KNO~~'N (if applicable) 14. PROJECT STREET ADDRESS (ifapplicablc)
<br />15. LOCATION OF PROJECT
<br />I6. OTI-TER LOCATION DESCRIPTIONS, IF KNOWN (see instructions)
<br />17. DIRECTIONS TO THE SITE 1 S. VATURE OF AC"11VITY
<br />- ly. PROJECT PURPOSE 20. REASON(S) FOR DISCHARGE
<br />'21. TYPES OF MATERIAL BEING DISCHARGED AND "THE AMOUNT OF EACH TYPE IN CUBIC YARDS
<br />22. SURFACE AREA IN ACRES OF WETLANDS OR OTHER WATERS FILLED
<br />23. IS ANY PORTION OF THE WORK ALREADY COMPLETE? Y13S NO [F YES, llESCR[t3E COMPLL'fED WORT.
<br />24. ADDRESSES OF ADJOINING PROPERTY OWNERS,
<br />25. LIST OF O"fHER CEK7IFICA"HONS OR APPROVALS/DENIALS RECELVED FROM OTHER FEDERAL, S1'A"I-E OR LOCAL AGIiNCIES FOR
<br />WORK DESCRIBED IN 'T'HIS APPLICATION.
<br />26. Application is hereby made for a permit or permits to authorize the work described in this application. I certify that the information in this
<br />application is complete and accurate.. I further certify that I possess the authority to undertake the work described herein or am acting as the duly
<br />authorized agent of the applicant.
<br />Signature of pplicant Date Signature of agent (if any) Date
<br />The applicatio ,~ must be signed by the person who desires to undertake the proposed activity (applicant), or it maybe 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 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 $10,000 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 Local/State/Federal Application Forms for Water/Wetland Projects
<br />Lake Owasso Boat Ramp DNR Waters Permit Application -Submitted March 17, 2009 Page 2 of 10
<br />
|