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APPLICATION FOR DEPARTMEI\`T OP THE ARMY PERMIT (33 CFR 325) OMB APPROVAL NO. 0710-003 Expires Dec 31 2004 The public burden for this collection of information is estimated to average 10 hours per response, although the majority of applications should require 5 hours or less. This includes the time for reviewing instvctions, searching existing data sources, gathering and maintaining time data needed, and completing armd reviewing the collection of information. Send comments regarding this burden estimate or any other aspect ofthis collection of information, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Service Directorate of hmfornmation Operations and Reports, 1215 JeBerson Davis Highway, Suite 1204, Arlin6non, VA 22202-4302; and to the Office of Management 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 subject to any penalq~ for failing to comply with a collection of infommation if it does not display a currently valid OMI3 control number. Please DO NOT RETURN your forum to either of these addresses. Completed applications must be submitted to the District engineer havingjurisdiaion over the location of the proposed activity. PRIVACI' ACT STATEMENT: Authorities: Rivers atmd Harbors Act, Section 10, 33 USC 403; Clean Water Act, Section 404, 33 USC 1344; Marine Protection, Research and Sanctuaries Act, 33 USC 1413, Section 103. Principal pugmose, Information provided on this foram will be used in evaluating the application for a permit. Routine uses. This information may be shared with the Department oflustice and other Federal, state, and local government agencies. Submission of requested information is voluntary; however, if information is not provided, the permit application cannot be evaluated nor can a nennit be issued ITEMS 1 THROUGN 4 TO BE FILLED IN BY THE CORPS l APPLICATION NO 12. FIELD OFFICE CODL- 13. DATE RECEIVED 14. DATE APPL]CATION COMPLETED YOU DO MOT NEED TO COMPLETE ITEMS 6-10 and 12-25 in the SHADED AREAS. A/! applicants must complete non-shaded items 5 and 26. If an agent is used, also complete item; 8 and 1 ] . This optional Federal form is valid for use only when included as art ofthis entire state application packet. 5. APPLICANT'S NAME Greg and Cindy Noble 8. AUTHORIZED AGENT'S NAME AND TITLE (an agent is not required) 6. APPLICANT'S ADDRESS 9. AGENT'S ADDRESS 7. APPLICANT'S PHONE NO. 10. AGENT'S PHONENO. 11. STATEMENT OF AUTHORIZATION (if applicable; complete only iJaulhorizing an agent) 1 hereby authorize to act on my behalf as my agent in the processing of this application and to famish, upon request, supplemental information in support ofthis permit application. APPLICANT"S SIGNATURE: DATE: 12. PROJECT NAME OR TITLE (see instructions) 13. NAME OF WATERBODY, IF KNOWN (if applicable) 14. PROJECT STREET ADDRESS (if applicable) 15. LOCATION OF PROJECT 16. OTHER LOCATION DESCRIPTIONS, IF KNOWN (see instructions) 17. DIRECTIONS TO THE SITE ] 8. NATURE OF ACTIVITY 19. PROJECT PURPOSE 20. REASON(S) FOR DISCHARGE 21. TYPES OF MATERIAL BEING DISCHARGED AND THE AMOUNT OF EACH TYPE IN CUBIC YARDS 22. SURFACE AREA IN ACRES OF WETLANDS OR OTHER WATERS FILLED 23. IS ANY PORTION OF THE WORK ALREADY COMPLETE? YES ~_ NO ~ IF YES, DESCRIBE COMPLETED WORK. 24. ADDRESSES OF ADJOINING PROPERTY OWNERS, 25. LIST OF OTHER CERTIFICATIONS OR APPROVALS/DENIALS RECEIVED FROM OTHER FEDERAL, STATE OR LOCAL AGENCIES FOR WORK DESCRLBED IN THIS APPLICATION. 26. Application is hereby made for a permit or permits to authorize the work described in this application. 1 certify that the information in this ap ication is complete and accurate. I further certify that I possess the authority to undertake the work described herein or am acting as the duly ~thorized agent of the applicant. 1.~ ' `~ Signa re o~ pl` t Date ~ Signature of agent (if any) Date The. pl~ to ust be signed by the person who desires to undertake the proposed activity (applicant), or it may be signed by a duly authorized agent if th estate n n Block 1 1 has been filled out and signed. 18 U.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction of any depart ent or agency of the United States knowingly and willfully falsifies, conceals, or covers up with any trick, scheme, or disguises a material fact or makes any false, fictitious or fraudulent statements or representations or makes or uses any false writing or document knowing same to contain any false, fictitious or fraudulent statements or entry, shall be fined not more than $10,000 or imprisoned not more than five years or both. ENG FORM 4345; Jul 97 EDITION OF FEB 94 IS OBSOLETE. (Proponent: CECW-OR) Minnesota Local/State/Federal Application Forms for Water/Wetland Projects Page 2