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Pend ) GP-rto-zoo4- 7— obf 'fl <br /> fend 2 Gv- �o • �ooa- T- 06 /q L- ' <br /> State of Wiscons n 41w". of�-'t'B� <br /> vdet(and Conservation Activities <br /> Department of N 3tural Resources General Permit Packet R3-07 <br /> www.dnr.wi.gov Form 3500-112 page 4 of 11 <br /> Notice:This applicati n form is required under Section 30.206,Wis.Stats.and ch.NR 310,Wis.Adm.Code.Failure to submit a complete <br /> application to the De artment at least 35 days prior to the date of proposed construction may result in dismissal of your application,forfeitures <br /> or other enforcemen.Personally identifiable information included on this form will be used to contact you and is not intended to be used for <br /> other purposes.It maybe made available to requesters under Wisconsin's Open Records law(ss.19.31-19.39,Wis.Stats.). <br /> Section 1:Landowner Information <br /> Name T Contact Qerson <br /> ar <br /> Mailing Address Email Address <br /> ll) 9 s kL 5 <br /> city��jj State Zip Phone Fax <br /> ✓t e. /a e &?L 5449 ( 7)5 <br /> Section II:Conse ationActivity-Referenceattachedmaps/photosandplans. <br /> Conservation Activity(s.NR 353.05) Nu ber of Activities <br /> Scrape <br /> Micro-Topogr phy <br /> Water Contro Structure(includes in-stream structures which are considered dams, <br /> such as weirs,tin whistles,ditch plugs with outlet pipes) <br /> Construction of Embankment / Dike(considered dams if across a watercourse) <br /> Ditch Fill / Ditch Plug(ditch plugs must have no outlet pipes) <br /> Breach Dike or Dike Removal(circle which applies) <br /> Other(please describe) <br /> Total Acres of Wetland Filled(berm/embankment/dike,not ditch fill) <br /> Approximate Wetland Acres Enhanced <br /> Approximate Wetland Acres Restored <br /> Approximate Wetland Acres Created <br /> Section III:Agent Information (DNR WMS,please send all correspondence directly to agent and applicant) <br /> Check one consultant Ocoetractor Contact Person (f fI <br /> Authorized Representative ❑Not Applicable -5TC(�e f' ev✓ISV)1^41 <br /> Mailing Address E-mail Address <br /> Zq Sana Ro�c� <br /> City State Zip Phone Fax <br /> 5 87! ( 7)5 ) -1/& <br /> Section IV: Site Ir formation <br /> Project Address Waterway Name <br /> ,p,//% /4Section Township Range E/W Check one �q Fe I Z-H e- County <br /> :IV/ W JUJ 15 0 N IS 1-0 ❑ city OTown ❑Village of Bu/,hG-r� <br /> Approximate Start Date Approximate Project End Date <br /> (Month/Day/Year) z I -Q 9 (Month/DayNear) J Z- 30-Za jp <br /> PC, �l I YiZ AJ Scu �ec . IS � aanJ 3 SESE 4 s-c lb� <br />