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State of Wisconsin Biolo icaErosion Control <br /> 9 =Shore <br /> Department of Natural Resources General Permit Packet R1-06 <br /> www.dnr.wi.gov Form 3500-108 page 4 of 8 <br /> Notice:This application 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 Department at least 35 days prior to the date of proposed construction may result in dismissal of your application,forfeitures <br /> or other enforcement.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 I:landowner Information <br /> (oP-NO -Z00g — r( — r'( I �flC( <br /> Name Contact Person <br /> So 4wr) <br /> Mailing Address Email Address <br /> 6Qz� W oaY �� F /It <br /> City State Zip Phone ax <br /> FilJ/ty Am I SQ'432 ( 963 ) and 2�SS ( 16^3 )0260zq,�6 <br /> Section II:Activity <br /> Check the box next to the type ofgeneral permityouare reques ting with this application <br /> ❑ Biological Shore Erosion Control ❑ Dry Fire Hydrant ❑ Pilings Seawall-Replace with Riprap <br /> ❑ Boat Ramp ❑ Fish Habitat Structure ❑ Pond-Landscape ❑ Weed Rake <br /> ❑ Clear Span Bridge ❑ Ford ❑ Pond-Stormwater ❑ Wildlife Habitat Structure <br /> ❑ Culvert ❑ Grading-Leu Than One Acre ❑ Pond-wildlife ❑ Riprap <br /> ❑ Dredging-Drainage District ❑ Grading-One Acre or More ❑ Riprap Repair/Replacement ❑ Other. <br /> ❑ Dredging-Utility Crossings ❑ Intake/Outfall Structure ❑ Seawall Replacement <br /> Section III:Agent Information <br /> Checkone ❑Consultant ❑contractor Contact Person <br /> ❑Authorized Representative ❑Not Applicable ` <br /> Mailing Address E-mail Address <br /> City State Zip Phone Fax <br /> Section IV:Site Information <br /> Project Address ,, Waterway Name /� <br /> 4a ed A) �u�� f06id C <br /> /</./�</ ,/4 Section Towns Ip Range Check one rye/ County <br /> V S` �� D N 1(0 ❑City ❑Town I village of <br /> Project Start Datet, p Approximate Project End Date <br /> (Month/DayNear) Al tvt 200/ (Month/DayNear) Q24M ,Za09 <br /> Will this project effect wetlands? ❑yes ❑No k(Unsore <br /> How did you arrive at this conclusion? <br />