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Water Resources Application for Project Permits <br /> �A Form 3500-053 R 08/09 Page 2 <br /> Applicant/ProjectName: JA In county: oetJt3 <br /> Latitude and Longitude Method if available <br /> De rees Minutes Seconds Method of Determining <br /> Latitude ❑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 �Ty Special status <br /> 9116KE WK LAKE �j Lake ❑ Stream ❑ORW/ERW ❑ 303(d) listed <br /> Yes No Wetlands: <br /> ❑ 54 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 /> E&etland Locator Tool ❑ Soils(NRCS maps) ❑ Other(specify) <br /> TftE//dnr.vVi.gov/wetiands/locating.htmI <br /> Section 7: Project Information Attach additional sheets as necessary) <br /> Duration: Anti ipated Project Start Date(month/day/year) Proj 4 1 Project End Date(month/year) <br /> 9 a�1u <br /> Photos: Provide holo ra hs of the"before"condition. Date of Photographs: <br /> Narrative of the Project: <br /> Provide a one to two paragraph description of the proposed project, including land and water alterations and intended <br /> use(s)of the project. .S65 K� A 3 <br /> Section 8:Attachments and Permit Access(Include appropriate attachments for each proposed activity.) <br /> The following attachments,together with this form, constitute this��e it application: (include all that apply) <br /> Attachment Name(s) ?.lfZKf f ain if �hf'PUGA I/o� <br /> 1 have obtained a copy of the construction site storm water runoff general permit from the department's Internet site. <br /> httD://dnr.wi.gov/runoff/Ddf/stormwater/oermits/construction/construction Dermit 5067831-3.Ddf <br /> Section 9: Certification&Permission <br /> Certification: I hereby certify that 1 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 of Owner/Authorized Representative(Print or Type) Title Telephone Number <br /> ew- <br /> Signatu Date Signed <br /> LEAVE BLANK-AGENCY USE ONLY <br /> Date Received Fee Received Construction Site ID# Docket#GP -W- Corps# <br /> Q-9 -Z-0 11 $ :50 -ISO 2otr-'l-Obee7 <br /> Initi I screening: �/ <br /> eCompleteness L�historic checked 2Aare species(NHI)checked ff wetlands checked <br />