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Water Resources Application for Project Permits <br /> Form 3500-053 R 08/09 Pa e 2 <br /> _ ApplicanVProject Name: VI ,r-L�,S S county: —r,s r-; <br /> Latitude and Longitude Method if available <br /> Degrees I Minutes 7 Seconds Method of Determining <br /> Latitude ❑ GPS <br /> ❑ DNR's Surface Water Data Viewer <br /> Longitude ❑Other(specify): <br /> Sectfon 61Watervua"s and Wetlands ` see Instnictions about`otentiaCadditional a lication 11 requirem11 ents J' <br /> Name(descriptionifunnamed)of closest waterbodies Type Special status <br /> �I e,kk cx,,j l kV e— [gLake ❑Stream ❑ ORW/ERW ❑ 303(d) listed <br /> Yes No Wetlands: <br /> ❑ ® 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 /> htto://dnr.wi.aov/wetlandsllocatino.html <br /> Sec`tioifi7 Pro ec itArmation tfactt additiorialisFieets as'necessa k„ x„ <br /> :tea.. �. .v� ,...mak:,,,.', ' ..,`, '4,- <br /> Durq+on: Anticipated P{ojSP�ect Start Date(month/day/year) Projected Prpject End Date(month/year) <br /> lQ - ,Vol y Le r 2�� 1 I p i— t 7-r >� ` \ <br /> Photos: Provide photographs of the"before"condition. Date of Photographs: <br /> Narrative of the Project: <br /> Provide a one to two pa agraph descriptio of he proposed project, inc ding la d and water alterations and intended <br /> u$$e(s)of the project. \v u.. w ✓gyp 4 G o 5 L-,U <br /> l/l S'h..r,-e�` N�`ai t'ev--.'I,to <br /> 5+ 0a°V, i;r}a$l!ndi "+ a :.2 ='a -',�.i. a:, a th to*!Yfi".+'.Y, A* x d a -� ib�"' ± 1 <br /> "Sec ow:� (tjachmA ani'PerronAccess',(�nclniie approprlate�attachmen 'Ir each propbsetl�achwthw � f <br /> The following attachments,together with this form, constitute this per{�it plication: (include that apply) <br /> AttachmentName(s) („Ocdfit�SKeA-J— P'T'nvS�� Mk�L✓�w. �hN *��e� t''`�hS <br /> 51,V re.k;--.¢r p .r <br /> ❑ I have obtained a copy of the construction site storm water runoff general permit from the department's Internet site. <br /> htt ://dnr.wi.�ovhunoff! df/stormwater/ ermits/constructiion/construction 2ermit S067831-3. df <br /> • BC iOnzg. thew <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 wner/Auth ed Representative(Print or Type) Title Telephone Number <br /> Signa re DA Signed <br /> x,daL,.¢E4VErBL"PINK-AGENCY USEiQNLY�r.`' _-^ i <br /> Date Receive, -00, <br /> @Fee Received Construction Slte ID#t Dockets gps�o> Corps# vqi la ' <br /> �Im,ip <br /> Lv�Corpp(et'ness is{orifi ehecked�: are species, (NHI)checked ,. etlar ds,checked �' <br />