Wetland ApplicationNA-026620-03B (V.2.01 for MS WORD) 02/14/03
Minnesota Local/State/Federal Application Forms for Water/Wetland Projects
USE THIS APPLICATION FOR ANY PROJECT AFFECTING A LAKE, RIVER, STREAM OR WETLAND,
INCLUDING:
Local Government Unit Approval Pursuant to Minnesota Wetlands Conservation Act (WCA)
Minnesota Department of Natural Resources (DNR) Permit to Work in Public Waters
Department of the Army Permit (33 CFR 325)
Note: The U.S. Army Corps of Engineers (COE) will forward application forms to the Minnesota Pollution Control Agency (MPCA) for
processing if state water quality certification is required from the MPCA. You do not need to send this application to the MPCA.
This application packet includes:
Part I: The BASIC APPLICATION and the COE APPLICATION to be filled out by all applicants (see Instructions).
PART II: The REPLACEMENT PLAN SUPPLEMENT to be completed only for projects that impact wetlands and require a
replacement plan for wetland mitigation. If you're not sure whether your project requires a replacement plan, call your Local
Government Unit (LGU) or Soil and Water Conservation District (SWCD) office for guidance.
Do not proceed with your project until you have received alt required approvals from your LGU, the DNR and the COE. If you wish to confirm
the status of your application at any time, contact the agencies directly (see Instructions, page 2). Proceeding with work before all required
authorizations are obtained may result in fines or other penalties, and may include a requirement to restore the project site to original
condition.
If you have questions or need assistance with filling out these forms, contact your local SWCD office, your LGU, your Area DNR Waters office,
or your COE field office (see Instructions, page 2).
If you believe that your project may be subject to watershed district, local zoning, or any other local regulations besides those of your LGU,
contact those office(s) directly. If you are a Federal Farm Program participant and your project affects a wetland or water body on agricultural
land, your eligibility for USDA benefits may be affected. Contact a Natural Resources Conservation Service office for further information.
A QUICK LOOK AT THE PROJECT APPLICATION PROCESS
Electronic files: Forms can be downloaded and filled out using Microsoft Word. Your input will be restricted to fill-in fields where users can enter text or check
boxes. These areas appear gray on the screen, but not on the printed document.
Send copies of these completed application forms to your LGU, your Area DNR Waters office, and your COE regulatory office.
Any of the agencies may make initial contact with you to: a) inform you that it has no jurisdiction over your project; b) request additional information needed; or
c) inform you of applicable fees.
When your application is considered complete and appropriate fees have been received (if requested) it will be distributed for appropriate review.
Following agencies' reviews, you will be informed if it has been approved, approved with changes or conditions, withdrawn, or denied.
For information about state laws, rules and regulations that direct this process go to the web site www.revisor.leg.state.mn.us. For information on U.S. Army Corps
of Engineers regulations go to the web site www.mvp.usace.army.mil.
Instructions for Part I
HELP 1: Every applicant must fill out Section 1. The applicant is the person, agency, company, corporation, or other organization that owns,
leases, or holds other legal rights to the land where the project is located. Indicate names of multiple applicants on a separate sheet.
HELP lA: Fill out Section lA only if you have designated an authorized agent. An authorized agent may be an attorney, builder, consultant,
contractor, engineer, or any other person or organization designated by the applicant to represent him/her in this process. An agent is not required.
HELP 5: Purpose, description and dimensions of project: State briefly (in a sentence or two) what you propose to do and why it is needed.
Also, describe whether your project will involve any of the following:
Construction of structures, filling, draining, dewatering, removing, excavating or repair.
Construction of an access path, bridge, culvert, dam, ditch, dock, driveway, riprap, road, sand blanket, shore protection, or tile line.
Construction of any structures on fill, piles or a float-supported platform. If so, describe.
Dredging or discharging (placing fill material) into a wetland or other water body (including the temporary placement of material). If so,
explain the specific purpose of the placement of the material (such as erosion control) and indicate how it will be done (such as with a
backhoe or dragline). If dredged material is to be discharged on an upland site, identify the location of the site.
Minnesota Local/State/Federal Application Forms for Water/Wetland Projects
Instructions, Page I
NA-026620-03B (V.2.01 for MS WORD) 02/14/03
Minnesota Local/State/Federal Application Form for Water/Wetland Projects
I For Internal Use Only
Application No. Field Office Code Date Initial Application Received Date initial Application Deemed Complete
PART I: BASIC APPLICATION
"See HELP" directs you to important additional information and assistance in Instructions, Page l.
1. LANDOWNER/APPLICANT CONTACT INFORMATION (See Help 1)
Name: [¥1aJc} Io60 ¢. DoZqnne ~t]ooO.~ Phone: (q ~-o~) q 7q 3
Complete mailing address: (c:> '"/ q ~ L. o~ ~. o.. L,,oc~7 "U~. C__. [.h c~ ~ hc~
lA. AUTHORIZED AGENT (See Help IA) (Only if applicable; an agent is not required)
Name: Phone:
Complete mailing address:
2. NAME, TYPE AND SIZE OF PUBLIC WATERS or WETLANDS IMPACTED (Attach Additional Project Area sheets if needed)
Name or I.D. # of Waters Impacted (if applicable; if known):
(Check all that apply): [~.Lake [--IRiver [~vVetland type [] I [] 1L []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
LnV.¢ Loc./ o,,-,c~ Ad,jo;~;,,0 C.,O.~+l-,.',cl- $,tc G,*¢
3. PROJECT LOCATION (Information can be found on property tax statement, property title or title insurance):
Project street address: 6,3 q 5 L-,,, Ice. ~,o,,, ? D r. Fire #: City (if applicable):
iA Section: Section: Township #: Range Cf: County: C
Lot #: Block: Subdivision: Watershed (name or Cf)
Attach a simple site locater map. If needed, include on the map written directions to the site from a known location or landmark, and
provide distances from known locations. Label the sheet SITE LOCATOR MAP.
4. TYPE 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 propose to construct the project. This is the
most important part of your application. See HELP 5 before completing this section; see What To Include on Plans (Instructions,
page 1). Attach PROJECT DESCRIPTION sheet.
O' ~h" OocZ. co,it b,~ ~eOr°r.:r~c'Jr¢]~
Footprint of project: 0 acresor 0 square feet drained, filled or excavated. '{'[,.. L~.{'l~,~d 'h~ Ot'Oq,'d~ ClCC-e'~(;
6. PROJECT ALTERNATIVES: What alternatives to this proposed project have you considered that would avoid or minimize impacts
to wetlands or waters? List at least TWO additional alternatives to your project in Section 5 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
PROJECTALTERNATIVES sheet if needed.
~o hl~'ec,~.nJ-,'~'es') o, bSe~4 o~oro~,~l ~ co, Il ¢,de,,,',~ ~cc~.~s 'lz ~,lce L,_,~7
7. ADJOINING PROPERTY OWNERS: For projects that impact more than 10,000 square feet of water or wetlands, list the complete
mailing addresses of adjacent property owners on an attached separate sheet. (See HELP 7)
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 of paper labeled WORK ALREADY COMPLETED. (See HELP 8)
9. STATUS OF OTHER APPROVALS: List any other permits, reviews or 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 mn familiar with the information
contained in this application. To the best of my knowledge and belief, all information in Part 1 is true, complete, and accurate. 1 possess
the authority to undertake the work described, or I am acting as the duly authorized agent of the applicant.
Signatukg, of a~fpLIcmnt (IJandownCr)' / ' ~ ~' Date Signature of agent (if applicable) Date
This block muS( be signed by the perso~ who desires to undertake the proposed activity and has the necessary property rights to do so. If only the Agent has signed,
please attach a'separate sheet signed by the landowner, giving necessary authorization to the Agent.
Minnesota Local/State/Federal ApplicatiOnpage 1 Forms for Water/Wetland Projects
Include an overhead view drawing showing the work to be undertaken and its relative location on the property. Show items such as
property boundaries or lot dimensions; location and extent of shoreline, wetlands and water; location and dimensions and footprint of the
proposed project, structure or activity (include length, width, elevation and other measurements as appropriate); points of reference such as
existing homes, structures, docks or landscape features; indication of north; and location of spoil and disposal sites (if applicable). Hand drawn,
computer generated or professionally prepared drawings are acceptable, as long as they contain all necessary information clearly, accurately,
and in adequate detail. Please include specific dimensions whenever possible. You may also include photos, if you wish.
HELP 7: For information regarding adjacent landowners, contact the tax assessor where the project is to be developed.
HELP 8: If any part of the work has already been completed, describe the area already developed. Include a description of structures
completed; any dredged or fill material already discharged (including type of material and volume in cubic yards); acres or square feet filled (if
a wetland or other waterbody); and whether the work was done under an existing permit (if so identify the authorization, if possible).
IIELP 9: Other permits, reviews or approval related to the project may include the following: conditional use permit; plat approval;
zoning variance; National Pollutant Discharge Elimination System permit; state disposal system permit (includes dredged material disposal);
watershed district/watershed management organization permit (stormwater, erosion, floodplain); environmental assessment
worksheet/environmental impact statement; hazardous waste site; fcedlot permit; groundwater appropriation perrrfit; or county/township
driveway/road permit. Are you aware of any archeological or cultural resource determinations or surveys completed concerning the project or
replacement site by the State Historic Preservation Office (SHPO) or others'? If yes, please explain on a separate sheet or attach a copy of any
determinations or surveys.
Final Checklists (Part 0
Have you completed all of Part I (Page 1), plus the Federal application (Page 2)?
[~Did you (and your agent, if applicable) sign Section 10 on page 1 ?
Have you signed the Application for the Department of the Army Permit (Page 2) to seek Federal authorization of your project?
Have you included the necessary attachments for Part I? Attachments must include:
[] Site Locator Map (Section 3)
~ Type of Project (Section 4) (if additional space was needed)
~ Overhead View of Project (Section 5 and HELP 5)
[~Project Purpose, Description and Dimensions (Section 5) (if additional space was needed)
Attachments may also include:
[] Applicant Contact Information (HELP 1) (if additional space was needed)
[] Project Location (Section 3) (if additional space was needed)
[] Project Alternatives (Section 6) (if additional space was needed)
[] Photographs
[] Adjoining Property Owners (Section 7) (if additional space was needed)
[] Work Already Completed Section (Section 8) (if you answered YES)
[] State Historic Preservation Office determination or survey
Submitting Your Application
Make three copies of the entire application and all attachments. Keep the original, and mail a complete copy of your application to each of the
local, state, and Federal entities listed below. Be sure to include Part I and all attachments with each application.
LOCAL: Send to the appropriate Local Government Unit (LGU). If necessary, contact your county Soil and Water Conservation District (SWCD)
office or visit the Board of Water and Soil Resources (BWSR) web site (www.bwsr.state.mn.us) to determine the appropriate LGU.
STATE: Send to your Area DNR Waters office, attention Area Hydrologist. If necessary, contact your county Soil and Water Conservation District
(SWCD) office or visit the DNR website (www.dnr.state.mn.us) to locate the Area Hydrologist for your location, or contact a Regional DNR office:
NW Region: NE Region: Central Region: Southern Region:
2115 Birchmont Beach Road N.E. 1201 East Highway 2 1200 Warner Road 261 Highway 15 South
Bemidji, MN 56601 Grand Rapids, MN 55744 St. Paul, MN 55106 New Ulm, MN 56073
Phone: 218-755-3873 Phone: 218-327-4416 Phone: 651-772-7910 Phone: 507 359-6053
FEDERAL: Send to the appropriate U.S. Army Corps of Engineers regulatory field office:
Brainerd:
U.S. COE, Regulatory Branch
10867 E. Gull Lake Drive N.W.
Brainerd, MN 56401-9051
Phone: 218-829-8402
St. Paul:
U.S. COE, Regulatory Branch
Army Corps of Engineers Centre
190 5th Street East
St. Paul, MN 55101-9051
Phone: 651-290-5375
La Crescent:
U.S. COE, Regulatory Branch
1114 South Oak Street
La Crescent, MN 55947-1338
Phone: 507-895-8059
Two Harbors:
U.S. COE, Regulatory Branch
1554 Highway 2, Suite 2
Two Harbors, MN 55161
Phone: 218-834-6630
WEB SITES: BWSR: www.bwsr.state.mn.us U.S. ACOE: www.mvp.usace.army.mil DNR: www.dnr.state.mn.us MPCA: www.pca.state mn.us
Minnesota Local/State/Federal Application Forms for Water/Wetland Projects
Instructions, Page 2
APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT (33 CFR 325) OMB APPROVAL NO. 0710-003 Expires Dec 31, 2004
The public burden for this collectiou 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 instructions, searclfing existing data sources, gnthering and maintaining the data needed, and completing and reviewing the collection of information. Send
conunents regarding this burden estimate or any other aspect of this collection of thformation, including suggestions for reducing this burden, to Department of Defense, Washington
Headquarters Service Directorate of Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington, 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 penalty for hilling to comply with a collection of information if it does not display a currently wdid OMB control number. Please DO NOT RETURN your form to
either of these addresses. Completed applications must be subnfitted to the District engineer having jurisdiction over the location of the proposed activity.
PRIVACY ACT STATEMENT: Authorities: Rivers and Harbors Act, Section 10, 33 USC 403; Cleau Water Act, Section 404, 33 USC 1344; Marine Protection, Research and
Sanctuaries Act, 33 USC 1413, Section 103. Principal pnrpose: Information provided on this form will be used in evaluating the application for a permit. Routine uses: This
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
infortrultion is not provided, the permSt application cannot be evaluated nor can a permit be issued.
ITEMS 1 THROUGH 4 TO BE FILLED IN BY THE CORPS
1. APPLICATION NO. 2. FIELD OFFICE CODE I 3. DATE RECEIVED I 4. DATE APPLICATION COMPLETED
YOU DO NOTNEED TO COMPLETE ITEMS 6-10 and 12-25 in the SHADED AREAS.
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 valid
for use only when included as part of this entire state application packet.
5. APPLICANT'S NAME
8. AUTHORIZED AGENT'S NAME AND TITLE (an agent is not required)
11. STATEIVIENT OF AUTHORIZATION (~flapplicable: complete only iflanthorizing an agent)
I hereby authorize to act on my behalf as my agent in the processing of this application and to furnish, upon request,
supplemental information in support of this permit application.
APPLICANT"S SIGNATURE:
DATE:
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
application is complete and accurate. I further certify that 1 possess the authority to undertake the work described herein or am acting as the duly
authorized agent of the al~plicant.
Date Signature of agent (if any) Date
The application must be signed by the person who desires to undertake the proposed activity (applicant), or it may be signed by a duly authorized agent if
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
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
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
Instructions For Part II
Complete those portions of Part I1: Replacement Plan Supplement for which information is readily available (such as location, existing land use, size
of impact area, etc.) A person certified in wetland delineation must determine items pertaining to specific wetland impacts (wetland type,
predominant vegetation, watershed name, etc.) Contact the local soil and water conservation district (SWCD) office for further information on
obtaining such items.
What to Include on Plans
Detailed overhead views of replacement site(s) (Part ll), as well as profile view(s) of replacement site(s) (Part II), may be either hand drawn,
computer generated or professionally prepared, as long as they contain all necessary information clearly, accurately, and in adequate detail. Please
include specific dimensions whenever possible. You may also include photos, if you wish.
Overhead views of Part I1 replacement site(s) should include the following items that pertain to your project: Property boundaries and/or lot dimensions.
Location and extent of shoreline, wetlands and water.
Location and dimensions of proposed project, structure or activity. Include length, width, elevation and other measurements as appropriate.
Points of reference (such as existing homes, structures, docks or landscape features).
Location of inlet and outlet structures.
Indication of north.
Location of spoil and disposal sites (if applicable).
Areas of wetland and upland plants established.
Profile views (side or cross-sectional views) should include the following items that pertain to your project:
Location and dimensions of proposed project, structure or activity. Include elevation, depth, soil profile, side slope and other
measurements as appropriate.
Proposed water level elevation.
Final Checklists
Part I1: Replacement Plan Supplement
[] Have you completed all of Part II (pages 3-5)?
[] Did you (or your agent) sign Section 19 on page 5?
[] Have you included the necessary attachments for Part II?
Attachments must include:
[] If the project includes any wetland banking (complete or partial), include Application for Withdrawal of Wetland Credits Form (Section 14)
[] If the project includes any project-specific replacements (complete or partial), include:
Description of Replacement Wetland(s) Construction (Section 15)
Copy of vegetation management plan (Section 15)
Scale drawing of overhead view or replacement wetland (Section 18)
Scale drawing of profile view of replacement wetland (Section 18)
Attachments may also include:
[] Additional description of Wetland Impact Charts (Section 11) (if additional space was needed)
[] Additional Description of Replacement Wetlands charts (Section 17) (if additional space was needed)
[] Additional soils information for created replacement wetland(s) (Section 18) (if available)
Note: To deposit surplus wetland credits in the State Wetland Bank, submit a Wetland Banking Application directly to your LGU (Section 16).
Preparing Your Application for Mailing
[] To apply for both state and Federal authorization, your application must include Part I (Page 1), the Federal application (Page 2), and
attachments as indicated on Final Checklist for Part I (Instructions, Page 2).
[] Your application must also include Part II (Pages 3-5) and additional attachments as indicated on Final Checklist for Part 1l (above).
[] Make three copies of the entire application and all attachments. Keep the original, and mail the three copies to the appropriate local, state,
and Federal agencies (see Instructions for Part 1 for addresses).
Minnesota Local/State/Federal Application Forms for Water/Wetland Projects
Instructions Page 3
PART Ih REPLACEMENT PLAN SUPPLEMENT
For axxi.~tance itt completing Part 11, contact your l~cal Government Unit or ct prqfexsional conxultant
11. DESCRIPTION OF WETLAND IMPACTS: Complete the chart below: 1) Use one row of boxes for each wetland impact; 2) If your project has more
than one wetland impact, reference your overhead view (part of Section 5) to this chart by identifying and labeling "first impact" and "second impact" on
your overhead view; 3) If you are identifying only one wetland type within a given wetland impact area, use the first dotted line and leave the others blank;
4) If you have chosen to identify more than one wetland type within a given wetland impact area, use the extra dotted lines to indicate each wetland type, and
identify predominant vegetation and size of impacted area for each separate wetland type within that impact area; 5) If you do not have access to some of
this information, call your LGtJ or SWCD ot'fice for assistance. (Photocopy chart./hr more impactx, if needed.)
Wetland Watershed County,
impact (as name or Section,
noted on number (if Township,
overhead known) Range
view)
DESCRIPTION OF WETLAND IMPACTS
Wetland type~ Predominant Size of area
vegetation in impacted
impacted (in acres or
wetland area square
feet)
Existing land use in project
area (check all that apply)
[]
First ....................................................... []
impact []
Second
impact
Housing
Commercial
Industrial
Parks/recreation areas
Highways and
associated rights-of-way
[] Forested
[] Farmsteads/agricultural
[] Vacant lands
[] Public and semi-public
(schools/gov't facilities)
[] Airports
Extractive (gravel
pits/quarries)
Other:
~lf you are identifying only one wetland type within a given wetland impact area, use the first dotted line and leave the others blank. If you have chosen to identify more
than one wetland type within a given wetland impact area, use the extra dotted lines to indicate each separate wetland type, and identify predominant vegetation and size
of impacted area for each separate wetland type with that impact area.
TOTALS OF AREA(S) IMPACTED FOR EACH WETLAND TYPE ON CHART (indicate at:rex [] or square feet I-"])
Type: 1:__ IL:__2:__ 3:__ 4:__ 5:__ 6:__ 7:__ 8:__ R:__
12. SPECIAL CONSIDERATIONS: Are you aware of any special considerations that apply to either the impact site(s) or the replacement site(s)? [] Yes [] No
(Examples: the presence of endangered species, special fish and wildlife resources, sensitive surface waters, or waste disposal site.) If YES, list and describe briefly.
13. SHORELAND IMPACT ZONE: Please identify each wetland impact site noted in Section 15 that is within 1000 feet of a lake or 300 feet of a river.
Minnesota Local/State/Federal Application Forms for Water/Wetland Projects
Page 3
14. HOW PROPOSED REPLACEMENT WILL BE ACCOMPLISHED: Indicate how proposed replacement will be accomplished (check only one box below
and continue as indicated):
['-] A~
Wetland banking only
Complete Application./hr Wid~drawal qfWetland Credits Form and include with your application. Copies of this form are available from your LGU, or
download a copy from www.bwsr.state.mn.us
Skip to Section 19, page 6 (You do not need to complete Sections 15-18).
[] B. Project-specific replacement only
Continue witb Section 15 below.
DC.
A Combination of wetland banking and project-specific replacement
Complete Application./hr Withdrawal t?fWetland Credits Form and include with your application. Copies of this form are available from your LGU, or
download a copy from www.bwsr.state.mn.us
Continue with Section 15 below.
15. DESCRIPTION OF REPLACEMENT WETLAND(S) CONSTRUCTION (Complete this section only if you marked Box B or Box C in Section
14 above):
Describe in detail how replacement wetland(s) will be constructed. If several methods will be used, describe each method. Details should include the
following: 1) type of construction (such as excavated in upland, restored by tile break, restored by ditch block or revegetated); 2) type, size and
specifications of outlet structures; 3) elevations relative to Mean Sea Level or established benchmarks or key features (such as sill, emergency overflow or
structure height); 4) what best management practices will be implemented to prevent erosions or site degradation; 5) proposed timetable for starting and
ending the project; and 6) a vegetation management plan. Write this description on a separate sheet of paper labeled DESCRIPTION OF REPLACEMENT
WETLAND CONSTRUCTION.
16. SURPLUS WETLAND CREDITS: If using project-specific replacement (Box B or Box C in Section 14 above), will the replacement result in any
surplus wetland credits that you wish to have deposited in the State Wetland Bank for future use? [] Yes [] No. If yes, submit a Wetland Banking
Application directly to your LGU. Copies are available from your LGU, or download a copy from www.bwsr.state.mn.us
17. DESCRIPTION OF REPLACEMENT WETLANDS: Complete the chart below: 1) Use one row of boxes for each wetland replacement site: 2) If
your project has more that one wetland replacement site, reference your overhead view (part of Section 5) to this chart by identifying and labeling "first
replacement site" and "second replacement site" on your overhead view; 3) If you are identifying only one wetland type within a given replacement site, use
the first dotted line(s) and leave the others blank; 4) If you have chosen to identify more than one wetland type in a given replacement site, use the extra dotted
lines to indicate each separate wetland type, and identify type(s) of replacement credits and "restored or created" for each separate wetland type with that
replacement site; 5) If you do not have access to some of the information, or if you do not know your replacement ratio, call your LGU or SWCD office for
assistance. Photocopy chart for more wetland replacements, if needed.)
DESCRIPTION OF REPLACEMENT WETLANDS
Identify Watershed County Section, Wetland Type(s) of replacement credits Restored
Wetland name or Township, Type~ (in acres orsquare feet) or
replacement number created?
site (if known) Range New Wetland Public Value Indicate
(as noted on Credits (NWC) Credits (PVC) R or C
overhead view)
Name of
First
replacement
site
Name of
Second
replacement
site
tCircular 39 wetland types: Indicate 1, 1 L, 2, 3, 4, 5, 6, 7, 8, R, or U. If you are
identifying only one wetland type within a given wetland impact area, use the first
dotted line and leave the others blank. If you have chosen to identify more than one
wetland type within a given wetland impact area, use the extra dotted lines to indicate
each separate wetland type, and identify predominant vegetation and size of impacted
area for each separate wetland type within that impact area.
TOTAL NWC TOTAL PVC
REQUIRED REPLACEMENT RATIO:
(If known)
Minnesota Local/State/Federal Application Forms for Water/Wetland Projects
Page 4
18. ADDITIONAL INFORMATION REQUIRED FOR PROJECT-SPECIFIC REPLACEMENT (Required only if you marked Box B or Box C in Section 14):
For projects involving at least some project-specific replacement, include the following additional information:
[] Two drawings to scale of the replacement wetland. Include both overhead view and profile (side view or cross-sectional view). See What to Include on Plans
(Instructions, Page 3) fbr a detailed description of what should be included in these drawings. Without drawings, your application will be considered incomplete.
[] For created replacement wetlands, include additional soils information (if available) that indicates the capability of the site to produce and maintain wetland
characteristics.
Note 1: For replacement wetlands located on pipeline easements, you need to receive endorsement of your project from both the easement holder and the Minnesota
Department of Public Safety's Office of Pipeline Safety. Before start of construction, the owner of any utilities must be notified. The landowner or contractor is
responsible for giving this notice by calling "Gopher State One-Call" at 652-454-0002 (Twin Cities Metro Area) or 1-800-252-1166 (alt other locations).
Note 2: For extensive or complex projects supplementary information may be requested at a later dated from one or more of the responding agencies.
Such information may include (but not be limited to) the following: topographic map, water table map, soil borings, depth soundings, aerial photographs,
environmental assessment and/or engineering reports.
19. SIGNED AFFIRMATION:
FOR PROJECTS INVOLVING REPLACEMENT BY WETLAND BANKING ONLY. To the best of my knowledge and belief, all information in Part 11 is true,
complete and accurate; and I affirm that the wetland losses will be replaced via withdrawal from an accoant in the State Wetland Bank.
FOR PROJECTS INVOLVING EITHER PROJECT-SPECIFIC REPLACEMENT ONLY OR A COMBINATION OF WETLAND BANKING
AND PROJECT-SPECIFIC REPLACEMENT:
Part A: The replacement wetland. 1 affirm that the replacement wetland was not:
Previously restored or created under a prior approved replacement plan or permit; AND
Drained or filled under an exemption during the previous 10 years; AND
Restored with financial assistance from public conservation programs; AND
Restored using private funds, other than landowner funds, unless the funds are paid back with interest to the individual or organization that funded the restoration; and
the individual or organization notifies the local government unit in writing that the restored wetland may be considered for replacement.
Part B: Additional assurances (check all that apply):
[] The wetland will be replaced before or concurrent with the actual draining or filling of a wetland.
[] An irrevocable bank letter of credit, performance bond, or other acceptable security has been provided to guarantee successful completion of the wetland replacement.
[] The wetland losses will be replaced via withdrawal from an account in the State Wetland Bank.
Part C. For projects involving any project-specific replacement: Within 30 days of either receiving approval of this application or beginning work on the project, 1
will record the Declaration of Restrictions and Covenants on the deed for the property on which the replacement wetland(s) will be located; and 1 will at the same time
submit proof of such recording to the LGU.
To the best of my knowledge and belief, all information in Part II is true, complete and accurate; and 1 affirm all statements in Part A and C, as well as
checked assurance(s) in Part B.
Signature or applicant or agent
FOR LGU USE ONLY
Replacement plan is (check one): [] Approved
Date
[]Approved with conditions (conditions attached)
[] Denied
LGU qffieial signature Date
LGU has receive evidence of title and proof of recording of Declaration of Restrictions and Covenants for Replacement Wetland:
County where recorded Date
Document # assigned by reeorder
LGU qffieial signature Date
Minnesota Local/State/Federal Application Forms for Water/Wetland Projects
Page 5
~ p f l ,' c ~ ~r : o ~u F ~ ~ L~ ~ ~r l~ ~ ~1
D~,.
LOT
SgRV' ¥S COg?ANY,
],AND URVE¥0RS
REGISTERED UNDI~R THE LAWS OF STATE OF MINNESOTA ' ·
7601 78rd Avenue North ~ 64'~'5~0~-~&~/PC
Fax No. §60-3§22
TC
969.69 Minneapolis, ~in~esota 55428 xO00. O
urve ors (¢erti, firate
TOP
Property ].ocated in section
. .2, Townshi'p 116, Range 23,
Carver County, Minnesota
TC
970,34
INVOICE NO. 58308
NC.
SCALE:' 1" = 30'
Denotes Iron Monument
Denol;es Wood Hub Set
far excavation only ,
DenOl;es ExisUng Els.vol;ion
Denotes, Proposed Elevation
Denotes Surface Drainage'
NOTE: Proposed grades ore subject
to results of soil tests, .
'Proposed building' Information -
must be checked with approved
building plan and development or
grading plan ,b, efore excavation
. ~-_ and construction,
~,'i~L.'~' ~Pr~oposed Top of Block .
:i~.1:.~-~ ]-~:.'. Proposed. Garage "r~oor
.~b4..,~ P~;oposed :Lowesl; Floor
Type of Building
' ',x)4 L.ICo0T' '
PROPOSED
RESIDENCE
\ TO
970,30
NOTE:Check sanitary sewer service depth
basement floor elevation may be
below service invert.
~ TC
Contour Line
Proposed Contour Line
t4. ~'%'- i~Ct~ ~'~ 0
.
Proposed
Lot 5~ Block 2, (.
WHITE':TAIL COVE ~c~ ~*
The .only 'easements shown ore from plats of record or information
provided by client,
We hereby certify that thls leo true and correct representatlbh of
a survey of the boundaries of the above described land and the .
location of all buildings and visible encroachments, if any, from or on
. ~-said land, .
.... >~'.. Surveyed by us this 22nd day of .November 21).00
~NGINEERING DEpT;
~'¢V', I¢~[Z '~ Charles F. Anderson, Minn, Reg., No.2i75~ or
.. ~fz¢-r,. W'hLL f t.~ , .Gregory R. Prasch, MinR Rog No, 24992
5 i Lo.c 4o 8