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Water Resources Application for <br /> ---Project�Perrnits .l <br /> Forn 3500-053 (R 9/12) Page 2 of 3 <br /> Name(description if unnamed)of closest waterbodies Type •' - Special Status <br /> Lake 0 Stream 0 ORW/ERW 0 3O3(d)listed - <br /> yes No Wetlands: <br /> ❑ )ZWetlands 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 /> NZ2�Wsconsin Wetlands Inventory ❑Wetland Delineation(attached report) <br /> Wetland Locator Tool Soils ❑ Other. <br /> ❑ htt /ldn m /t edand /lam ht I ❑ (NRCS maps) <br /> Applicant/Project Name: County <br /> Latitude and Longitude Melhotl(if available) <br /> Degrees Minutes Seconds Method of Determining <br /> ❑ GPS <br /> Latitude ❑ DNR's Surface Water Data Viewer <br /> ❑Other. <br /> Longitude <br /> • Anticipated Project Start Date(mm/ddlyyyy) Anticipated Project End Date(mm/dd/yyyy <br /> Duration: e tT / �3 <br /> l Date of Photographs(mm/dd/yyyy) <br /> Photos: Provide photographs of the"before"condition. --7 7 /2 <br /> / G <br /> Narrative of the Project <br /> Provide a one to two paragraph description of the proposed project,including land and water alterations and intended use(s)of�� <br /> project. Ole- (.J-U" �1��2 �'D MS II rrYf7 -IG- A Sr�w(1 �a�r //arc-. 0_ G.L <br /> �l lrt-ecZo G)e Lnl� �b �le byti(A I G�� 1 � <br /> The following attachments,such as the construction Erosion and Sediment Control(form 3500-052A)and the Post-Construction Storm <br /> Water Management(form 3500-0526)for a storm water construction permit application,constitute this permit application: (include all <br /> that apply) <br /> Attachment name(s): ' <br /> I have obtained a copy of the construction site storm water runoff general permit from the <br /> epartment's intemet site: hto//dnrtai Oov/tooiGStormwater/constructioo/formshtml <br /> certification: I hereby certify that I am the owner or authorized representative of the owner of the property which is the subject <br /> of this Permit Application. I certify that the information contained in this form and attachments is true and accurate. I certify that <br /> the project will be in compliance with all permit conditions. I understand that failure to comply with any or all of the provisions of <br /> the permit may result in permit revocation 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 this <br /> notice and application,and to determine compliance with any resulting permit coverage. <br /> Name pf Owner/A�onze Representative(please print) Title Phone Number <br /> l/',f 3 Date Signed 657 'Z Y9 Pal <br /> Signature of pp' ni <br /> ZP 9//3 <br />