Wetland Application
NA-026620-03 B
(V202 for MS WORD) O~/12/04
Minnesota Local/State/Federal A plication Form for Water/Wetland Pro'ects
For Internal Use Only
Application No. Field Office Code Date Initial Application Received Date initial Application Deemed Complcte
PART I: BASIC APPLICATION
"See HELP" directs you to important additional information and assistanee in Instructions, Page],
I. LANDOWNER/APPLICANT CONTACT INFORMATION (See Help I)
Name: ....1\ <:, ,,¡, ( ~\.<;'''''1v,S~C'.\ L<-. C. Phone: 'Î S- ) _C¡t:t'i- tIll Š
Complete mailing address: T" ,-, " . '), I' ...I. r Ii, f., ,ilt .:','''- 3~ ,
r1s2c: \'t"~I('~r \'Y'f.-\....-,. :<~¿:·.'\tf<·'I"~eV"V\ oJ
I A. AUTHORIZED AGENT (See Help IA) (Onll' ilapplicahle: (//1 agent is not required)
Name: 'KV5C^ E.\\:^~e(.~ Phone: 4:,]. - 3S,-,' "S-u00
Complete mailing address: . , , ' .i "
(..{ 3i..l Ld....e.. 'i)-I(~L'" £~(~$,.'è..,r m", ~)s .:n ì
2. NAME, TYPE AND SIZE OF PUBLIC WATERS or WETLANDS IMPACTED (Att,leh Additiollal f'miect Irm shcets if needed)
Name or LD. # of Waters Impacted (if applicable; ifknown):
(Check all that apply): DLake DRiver ~WetlandtypeKi I D IL D 2 œJ 3 D4 D 5 D 607 D ~
Indicate size of entire lake or wetland (check one): 5Q Less than 10 acres (indicate size: t.':; ) D 10 to 40 ,lcres D Greater than 40 acres
^U~>
3, PROJECT LOCATION (Information can befÒund on propertv tax statement, pmperl1' title or title insurance)'
Project street address: Fire #:
!4 Section: IV ,; ,,:,..: SeclIon: <5 Township #: I j & I'J Range #: ¿ ~ W
Lot #: I3l0ek: Subdivision: Watershed (name or #)
Attach a simple site locator map. Ifneeded, include on the map written directions to the site from a known location or landmark, and
provide distances fì'om known locations. Label the sheet SITE LOCA TOR MAP. ~~ ê c:: II- --l k c IA.. .,Jl..i::~ ~ \ , ... .(, ~'1 ? l"..\
City (if applicable): ( /lit: I\n4£''; -< ""
County: C. AllUir-11....
4. TYPE OF PROJECT: Describe the type of proposed work. Attach TYPE OFI'ROJIX'Tsheet ifneeded
i'c\~,j\~ <. l;<'è~'& C':":\~\o/\..A<:....-\ "~J'
5. PRO./ECT PURPOSE, DESCRIPTION AND DIMENSIONS: Dcscribe what you plan to do and why it is nccdcd, how you plan to
construct thc project with dimcnsions (length, width, depth). area of impact, ,lIld when you propose to construct the project. This is thl'
most important pal"t of your application. See HELP 5 before completing this section; see What To Include on Plans (Instructions,
page I). Attaehf'ROJECTDESCRIPTIONsheet. Ex"\ê'V\~~~;"ù'C 'f:.;rcl.......LX?& G.1.V'\-ê', ~e.¿ P-'5
Footprint of project: .13 acres or S'}S"þsquare feet draine(~r excavated.
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 bc "no
build" or "do nothing"), and explain why you chose to pursue the option described in this application ovcr these ,dternatives. Attach
PROJECTALTERNATJVESsheetifneeded. .\""" . \., -'ó', ,- .,t;:) ^,; A"L' _~' <.!. .,-.".... ìì>~10")~'" i...J..."'¡::
\ u.,-'............ IV'-', ·1 .t.......uv-'t- u____ ¿.... _...~ _ ,~,~~ ' - "--"'" .,,~
',e ~jC;\v...~,^\ . ~"'- ~c \.." Wùv..\& \~.rO,-;¡JLé- C¿c.c.~(;~ +....;> Co>r-t......", '-t ~d1. (' ,
7. ADJOINING PROPERTY OWNERS: For projects that impact more than 10,000 square feet of water or wetlands, list the complcte
mailing addresses of adjacent property owners on an attached separate sheet. (See HELP 7) (1)/ A-
S. PORTION OF WORK COMPLETED: Is any portion of the work in wetland or water areas already completed') 0 Yes ~ No. If
yes, describe the completed work on a separate sheet of paper labeled WORK ALREADY COMPLETED. (See HELP S)
9. ST A TlJS OF OTHER APPROVALS: List any other permits, reviews or approvals related to this proposed project that arc either pending or
have already been approved or denied on a separate attached sheet. See HELP 9. Gt.L t\ 'I.~' £.\7> 'i<:..e,,;~"'.'Ùe~' ...:.:-\""
Li:.>II..<.!......Uf3 -f\CA~_ I
III. I am applying for state and local authorization to conduct the work described in this application. I am bmiliar with the II1formation
contained in this application. To the best of my knowledge and belict~ all information in Part I is true, complete, ,lI1d accurate. I possess
the authority to undertake the work described, or I am acting as the duly authorized agent of the applicant.
, -~ , ~./~/ /"./
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,
Date S(!',I1i1tllre o(agel1t (i(III)f'limhle)
Signllture o(ilf'plicant (Landowner)
nlll"
This block must he signed by the person who desires to undertake t he prop~)Sed activity.al,,1 has thc ncccssary.]Jropeny riglns to do so. Ifonly the Agent has signed,
please attach a separate sheet signed by the landowner, giving necessary authorization to the Agent.
'"
Minnesota Local/State/Federal Application Forms for Waler/Wetland Projects
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APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT (33 CFR 325)
OMB APPROVAL NO. 07]0-003 Expires Dec 31, 2004
The publi<.: hurden for this collection of information is estimated to average 10 hours per response, although thc majority of applj<.:ations should require 5 hours 0[" less. This includes
thc time for rcviC\ving instructions, searching existing data sources, gathering and maintaining the data needeò, and cDll1plcting and reviewing the collectioll of information. Send
comments rcg,¡rding this burden estimate or any other aspect of this collection ufinform<.\tion, including suggestions for reducing this burdcn, to Dl'partmcnt ofDcfcnsc, \Vashing!(}1l
Headquarters SL'rvicc Directorate of Information Operations and Reports. 1215 Jefferson Davis Highway, Suite 12()4, Arlington, VA 22202-4){)2: and to the: Office of Management
and 13udget. Paperwork Reduction Project (0710-0003), Washington, DC 20503. Respondents should be a\Vill'C that notwithstanding any other provi ~iol1 of!a\v, no person shall be
subject to any penalty for failing to comply with a collection of information ifit does not display a currently vidid 01'\/113 contrul number. Please DO NOT RETURN your form to
either of these addn:sscs. Completed applications must be submitted tu the District engineer having jurisdiction O\'L'r the location of the proposed i\cti"il y
PRIVACY ACT STA TEJ\'1E!\'T: Authorities: Rivers and Harbors Act, Section 10,33 use .:t03; Clean Wat!.:r Act, Section404, 33 use 134':+: ~bri!le Protectioll. Rcs!.:arch ;md
S:lIH.:tuari!.:s Act. 33 use 1413. Section 103. Principal purpose: Information rrovidcd oll1his form will be used ill C\~dll;lting the applic\!ion j"()r i\ permit. Routine uses: This
information l11ilY be shared with the Department or Justice and other Federal, state, and IOGtI govern me lit agencies. Suhmission ofreqllestcd in Ùlîl1~\tioll is \olulltary; hmvcvl'r. i I
information is not provided, the permit application cannot be evaluated nor can a permit be' isslled.
l. APPL.ICATION NO,
ITEMS I THROUGH 4 TO BE FILLED IN BY THE CORPS
/2. FIELD OFFICE CODE I J. DATE RECEIVED 14. DATE APPLICATION COMPLETED
YOU DO NOT NEED TO COMPLETE ITEMS 6-10 and 12-25 in the SHADED AREAS.
AI! applicants must complete non-shaded items 5 and 26. If an agent is used. also completc items 8 and II. This optional Federal form is valid
for use only when included as part of this entire state application packet.
5 APPLICANT'S NAME
:. .\ (.;. c;.( LIiI......^VI...>.<.,.et\ l.L c..
..~#-- '\ 2...(.) ''fr;,- t -J.~'~1 .'\'\(..;
6. APPLICANT'S ADDRESS iõJ1.i:>·. 'V~¡"N" vV\-'"
7. APPLICANT'S PHoNE NO. q S .2."';~(t.l(¡ ,U:t-t. S-
8. AUTHORIZED AGENT'S NAME AND TITLE (an '¡gent is not required)
I) C~ , R
9.AGENT'SADD ESS 4 3Lf. Lc.~~... St. FHJS~ol¿41.11\ 5'>53
10. AGE1':!T'S PHON,? NO. c¡ tf>l-.WO .~' 5000
] 1. STATEMENT OF AUTHORIZATION (ifupplica/¡/c: complete only ifollthorizillg Oil O);CIII)
I hereby authorizc to act on my behalf as my agent in the processing of this application and tnlÜrnish, upon requcst.
supplemcntallnlormatlOn In SUPPOlt of thIs permIt application
APPL.ICANT"SSIGNATURE \ '.;:_' ~~ DATE: /ö!/-/c'/
f't'-ik. rTl.¿~cQøJ
13. NAME OF WATERBODY, IF KNOWN (if applicable)
'?,' . c:....,cx.>Jl.lc..~..L..
IS. LOCATION OF PROJECT
16. OTIIER LOCATION
Sc ¿... 9:.\- t:. I~
18. NATURE OF ACTIVITY iRoc..S<... ~!.-\~tµ"
20. REASON(S) FOR DISCHARGE IV I À-
17. DIRECTIONS TO THE SITE
19. PROJECT PURPOSE (i.tl GAQ." ,
2 I. TYPES OF MATERIAL BEING DISCHARGED AND THE AMOUNT OF EACH TYPE IN CUBIC YARDS IJIA
~ 7 $'r; ~ f-. . \ ~ Ì\<..;:i t:..
NO ~IF YE~, DESCRIBE COMPLETED WORK.
25. LIST OF OTHER CERTIFICATIONS OR APPROY¡\LS/DENIALS RECEIVED FROM OTIIER FEDERAL, STATE OR LOCAL AGENCIES FOR
WORK DESCRIBED IN THIS APPLICATION, ~o.. -t "\£ j\.e.~--v
26. Application is hcreby made for a permit or permits to authorize-thc work deseribcd in this application. I certify th:¡t thc information In this
application is complete and accurate. I further certify that I possess thc authority to undertake the work described hcrein or am acting as the duly
authorized agent of the applicant.
í ) G-....s¿ ¿Çj/é'<-.-- /~ /, 1-/ 'i
Signature of applicant ¡)+'- <,4Üt<;"J,1<;SS¿¡\ Date Signature of agent (irany) Date
c:.,c... é... "
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 ,I'
the statement in ßloek I J has been filled out and signed. 18 U ,S,c, Seetion ] 00 I provides that: Whoever, in any manncr within the jurisdicrionorany
department or agency of the United States knowingly and willfÜlly falsifies, conceals, or covers up with any trick, scheme, or disguises a material factor
makes any 1:11se, fìctitious or traudulent statements or representations or makes or uscs any ¡¡lise IVliring or document knowing same to contain any ¡¡lise,
fictitious or fraudulent statements or entry, shall be fined not more than S I 0,000 or imprisoned not more than five years or both.
ENG FORM 4345, Jul 97 EDITION OF FEB 94 IS 0I3S0LETE. (Proponent: CECW-OR)
Minnesota Local/State/Federal Application Forms for Waler/Wetland Projccls
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