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Water Resources Application for Project Permits <br /> Form 3500-053(R 08810099) Page 2 <br /> Applicant/Project Name: —Twky"A S CAOCounty: u.re..nwr t r <br /> Latitude and Longitude Method if available <br /> De rees Minutes Seconds Method of Determining <br /> N Latitude 7 ❑GPS <br /> PErDNR's Surface Water Data Viewer <br /> Longitude qZ / 31,3"L,/ ❑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 /> Lake ❑Stream ❑ORW/ERW ❑303(d)listed <br /> Yes No Wetlands: <br /> ❑ M 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 /> hfto://dnr.wi.gov/wetiands/locating.htmi <br /> Section 7: Project Information Attach additional sheets as necessary) <br /> Duration: Anticipated Project Start Date(month/day/year) Projected Project End Date(month/year) <br /> O 200 3 2A 0 <br /> Photos: Provide photograph 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. <br /> Section B: Attachments and Permit Access(Include appropriate attachments for each proposed activity.) <br /> The following attachments,together ith this form, constitute t is permit applicatf°� nclude ail t�hattapply,) , n <br /> AttachmentName(s fQwt T crl r�(�� �p) (1�i1U`r <br /> � Afi�u �tve*1LW p wtrlb; ` Pzo��r NtbaaAnc� <br /> I have obtained a copy of the construction site stone water runoff general permit from the department's Intemet site. <br /> htto://dnr.wi.cov/runoff/Ddf/stormwater/Dermitslconstruction/construction permit S067831-3.odf <br /> Section 9: Certification&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. 1 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 /> Nam f Owner horized Representative (Print or Type) tle Telephone Number <br /> to l 2 D <br /> Sig Dateigne <br /> Dk,,,, <br /> LEAVE BLANK-AGENCY USE ONLY <br /> Date Receives/y 6 4 Fee Received Construction Site ID# Docket# Corps# <br /> Initial r <br /> ❑Completeness ❑Historic checked ❑ Rare species(NHI)checked ❑Wetlands checked <br />