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Water Resources Application for Project Permits <br /> Form 3500-053 R 08109 Page 2 <br /> Applicant/Project Name: County: <br /> Latitude and Longitude Method if available <br /> Degrees Minutes Seconds Method of Determining <br /> Latitude [I GPS <br /> ❑DNR's Surface Water Data Viewer <br /> Longitude ❑Other(specify): <br /> Section 6:Waterways and Wetlands see Instructions about potential additional apRlication requirements) <br /> Name(description if unnamed)of closest waterbodies Type Special status <br /> 131c, /ra �w J-'PFKJ�— jA Lake ❑Stream ❑ ORW/ERW ❑303(d)listed <br /> Yes No Wetlands: <br /> ❑ g Wetlands will be filled excavated or disturbed during construction or as part of this project. <br /> The presence of wetlands has been evaluated using:(check all that apply) <br /> ❑Wisconsin Wetlands Inventory ❑Wetland Delineation(attach report) <br /> ❑Wetland Locator Tool ❑Soils(NRCS maps) ❑Other(specify) <br /> httD//dnr.wi.aov/wetlands/locating.html <br /> Section 7:Project Information Attach additional sheets as necessary) <br /> Duration: Anticipatep Project Start Date(month/dayryear) Projected Project nd Date(month/year) <br /> I DAY 1 6Rz 0(m Ij 1 09 07 it <br /> Photos: Provide photographs of the"before"condition. Date of Photographs: 8 I 1 <br /> Narrative of the Project: <br /> Provide a one to two paragraph d s pbo f q proposed project,including,) nd and water alterations and intended <br /> use(s)ofthe project.L.a)t'-j �"I�'f�-i`tetd S1�le. oJu'• -t"i� t Fabric {or G-kerelivie. e� C; <br /> 1, q rk. <br /> _Sect on 8:Attachments and Permit Access (Include appropriate attachments for each proposed activity.) <br /> The following attachments,together with this form, constitute this permit application:(include all that apply) <br /> AttachmentName(s) "Fie-e. Alrplic�c- 3 00 - 6:53,A` &"errxj <br /> p o.-e ke A11a-c M&'V-J R I- OQ, <br /> to I have obtained a copy of the construction site storm water runoff general permit from the department's Internet site. <br /> httpJ/dnr.wi.aov/runoff/Ddf/stormwater/permits/construction/construction permit S067831-3.Ddf <br /> Section 9: Certification 8:Permission <br /> Certification: I hereby certify that I am the owner or authorized representative of the owner of the property which is the <br /> subject of this Permit Application. I certify that the information contained in this form and attachments is true and <br /> accurate. I understand that failure to comply with any or all of the provisions of the permit may result in permit revocation <br /> and a fine and/or imprisonment or forfeiture under the provisions of applicable laws. <br /> Permission: I hereby give the Department permission to enter and inspect the property at reasonable times,to evaluate <br /> this notice and application, and to determine compliance with any resulting permit coverage. <br /> Name <br /> +of Owner/Authorized Representative(Print or Type) Title_ 1 Telephone Number <br /> CS"e- t✓D -K1 rig �{AM�O'1.JhP Y' �7/Jr- 966- /979 <br /> Signatur Date Sign 'J <br /> LEAVE BLANK-AGENCY USE ONLY <br /> Date Received Fee Received Construction Site ID# Docket#6I-Np- Corps# <br /> g '9 -2_0I1 $ ATO •°0 2Olf- 7—O <br /> Init' screening: �/ <br /> Completeness Lrs historic checked tnl Mare species(NHI)checked etrvetlands checked <br />