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State or Wisconsin Deparment of Natural Resources Water Resources Application for <br /> dmwigov Project Permits <br /> (t .` Form 3500-053 (R 9/12) Page 1 of 3 <br /> Notice: Pursuant to chs.30 and 31,Wis.Stats.,ch.281,Ws.Stats, and s.283.33,Ws.Stats.,this form is used to apply for coverage under <br /> the state construction site stone water runoff general permit,and to apply for a state or federal permit or certification for waterway and wetland <br /> projects or dam projects.This tori and any required attachments constitute the permit application. Failure to complete and submit this <br /> application form may result in a fine and/or imprisonment or forfeiture under the provisions of applicable laws including s 83.91,�NlLs.Stats. <br /> Personal information collected will be used farad administrative purposes and may be provided to requesters to thee^ent mixed by�L'p rte's <br /> Public Records Laws ss.19.31-19.39,Ws.Stats. . V�1/hh 9 <br /> Use this form for(check all that apply): '7 . IBZL[pp <br /> Work in public waters(DNR -ch.30,Wis.Stats.) ❑Storm water NOI -New land disturbing consVu'e1`iS)MCti y <br /> ❑ Work in waters of the U.S(Corps of Engineers) ❑ Storm water NOI -Renewal FIN# <br /> ❑ Permit for Wetland Fill(DNR or Corps of Engineers) ❑ Dam projects(DNR or Corps of Engineers) <br /> Read all instructions provided before completing.If additional space is needed,attach additional pages. <br /> Information <br /> AMName(Intl.,Org.or Entity) Author¢etl Representative Title <br /> Ys 16M5- Wl SehF Owner <br /> Mailing Address City State ZIP Code <br /> 2Z( � z �cst �6 v 1461,0 <br /> Emailddress Phone Number(Ind.area code FAX Number(inti. area code) <br /> bwrl1 � �l�lul. e cod FAX <br /> 21L-ydq - 1l0I <br /> Name Intl.,Org.or Entity) Conrad Person • Title <br /> Y s •. CkLr gf- s1v� 1 o <br /> Mailing <br /> Z�( tl� ss� City State ZIP Code <br /> 7 L,� NY (00)6 <br /> Email Address - Phone Number(inti.area code) FAX Number(incl.area code) <br /> 5( 41 <br /> Section 3:-Other Contact Information Idheck one) <br /> ❑Consultant or Plan Preparer ❑Contactor ❑ gent OherIf Other,specify: Se rL` <br /> l� <br /> Name(Ind.,Org.or Entity) Conte Pe n Title <br /> Mailing SAddtate Cdy� Y1�� State ZIP NY tocif 0 <br /> ZZ � <br /> Email Address Phone Number(inG.area code) FAX Number(ind.area code) <br /> b��ol.�.. <br /> Project or Site Location <br /> ject Name • County ❑ City Town ❑ Village <br /> �us� G6 (N�e 26 (�urne (1 of w7 <br /> Location Address/Description <br /> 2916/ L.c�(r N ,e-Section 5: Location Information <br /> Create a map depicting the project location or the perimeter of the construction site(land disturbance)and relationship to nearby water <br /> resources using the Surface Water Data Viewer hit 7/d g tt 'G rt t / d 1 or a 7.5-minute series topographic map. <br /> You can print the map and then draw the location on the map. <br /> Provide the section,range,township information and if available,the Latitude and Longitude information. <br /> PLSS(Public Land Survey System) Method <br /> Quarter-Quarter Quarter Section Townyhhip Range If this site is not wholly contained on the <br /> WS s N ,� ❑W quarter-quarter section,more description: <br />