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State of,Wisconsin Fl Water Resources Application for Project Permits <br /> Department of Nalural Resources Form c Fo3500-053(R 08/09) Page 1 <br /> dncwi.gov A sc'0 <br /> Use this form for(che k all that apply): 'V �p Notice: This form is used to apply for coverage under the <br /> �.` state construction site storm water runoff general permit, <br /> ),Work in public watjers(DNR—ch. 30, Wis. Stats.) Rjp,4 and to apply for a state or federal permit or certification for <br /> ❑Work in waters of the U.S(Corps of Engineers) waterway and wetland projects or dam projects. This <br /> application form is authorized by chs 30 and 31,Wis. Stats, <br /> for Alterations to Public Waterways,ch.281,Wis.Stats,for <br /> ❑ Permit for Wetland Fill(DNR or Corps of Engineers) Wetland Fill and s.283.33,Wis. Stats.,for Storm Water <br /> ❑Storm water NO[-+New land disturbing construction activity Discharges. Personally identifiable information on this form <br /> ❑ Storm water NQI—Renewal FIN# may be used for other program purposes and may be made <br /> ❑ Dam projects(DNIR or Corps of Engineers) available to requestors under Wisconsin's Public Records <br /> laws and be posted on the Department website. This form <br /> Read all instructions provided before completing. If additional and any required attachments constitute the permit <br /> space is needed, attach additional pages. application.Failure to complete and submit this application <br /> form may=ions <br /> a fine and/or imprisonment or forfeiture <br /> under the provisions of applicable laws <br /> Section 1:A licantlllnformation <br /> Applicant Name(Indio., Org. or Entity) Authorized Representative Title <br /> Mailing Address i City State Postal Code <br /> J I W AN' Gb4'WI'NW /L <br /> E-mail address Telephone Number include area code) Fax Number(include area code) <br /> n� w AUa - - 6aLl3 <br /> Section 2: Landowner Information if different than Applicant) <br /> Name(Organization or Entity) Contact Person Title <br /> Mailing Address City State Postal Code <br /> E-mail address Telephone Number(include area code) Fax Number(include area code) <br /> Section 3: Other Contact Information check one): <br /> ❑Consultant or Plan Preparer Contractor ❑Agent ❑ Other If Other, specify: <br /> Name(Organization or Entity) _ Contact Person Title <br /> ` VAM. Qt UNP � f P, OWNaL <br /> Mailing AddressCity State Postal Code <br /> a R,151t oa way w1 -:5,48H3 <br /> E-mail addTelephone Number(include area code) Fax Number(include area code) <br /> G0� 3 ss CON N� - 9 - S 63q <br /> Section 4: Pro ect or Site Location <br /> - t6_Site Name(if any) County Municipality <br /> Locafion Address/Description <br /> IM CnQW/ PO 6_ S ( El City Village Township <br /> Section 5: Location Information <br /> Create a map depicting the perimeter of the construction site(land disturbance)and relationship to nearby water <br /> resources using the Surface Water Data Viewer hfto://dnr.wi.gov/ora/water/data viewer htm or a 7.5-minute series <br /> to graphic map.You can print the map and then draw the location on the map. <br /> Provide the section, range, township information and if available the Latitude and Longitude information <br /> PLSS Public Land Sunny S stem Method <br /> Quarter-Quarter Quarter I Section I- Township Ran a n If this Directiosite is not wholly contained <br /> [] W I�NE NW NE I \ b E on the quarter-quarter section, <br /> `TL/ N f k more description: <br /> Loi y V b f2�0 <br /> h-ockla IN 6QNt Lo7S ��� <br />