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Bu.r.w-H- Co• Zo,�,�..^+�- ��,C�j �� �� -2 <br /> State of Wisconsin O �U� 1L11aterQesources Application for Project Permits <br /> Department of Natural Resources 6 Form 3500-053(R 08109) Page 1 <br /> dnr.wi.gov <br /> Use this form for(ch ck all tKat apply): This form is used to apply for coverage under the <br /> sta nstruction site storm water runoff general permit, <br /> ]ffi Work in public waters(DNR—ch. 30,Wis. Stats.) and to apply for a state or federal permit or certification for <br /> "[�'Work in waters of the U.S(Corps of Engineers) waterway and wetland projects or dam projects. This <br /> application form is authorized by chs 30 and 31,Wis.Stats, <br /> for Alterations to Public Waterways, ch.281,Wis.Stats,for <br /> ❑ Permit for Wetland Fill (DNR or Corps of Engineers) Wetland Fill and s.283.33,Wis. Stats.,for Storm Water <br /> ❑Storm water NOI—New land disturbing construction activity Discharges. Personally identifiable information on this form <br /> ❑Storm water NO[—Renewal FIN# may be used for other program purposes and may be made <br /> ❑ Dam projects(DNR or Corps of Engineers) available to requestors under Wisconsin's Public Records <br /> laws and be posted on the Department website. This form <br /> Read all instructions provided before completing. If additional and any required attachments constitute the permit <br /> space is needed, attach additional pages. application. Failure to complete and submit this application <br /> forth may result in a fine and/or imprisonment or forfeiture <br /> under the provisions of applicable laws. <br /> Section 1: A ifcant Information <br /> Applicant Name(Indiv., Org. or Entity) Authorized Representative Title <br /> Mailing Address City State Postal Code <br /> /Jatt9:Z1-Al VD, <br /> m ii address Te phone Kh 1 er include area code) Fax Number(include area code) <br /> Section ' <br /> 2,LaridoWn"er14orm4tton If,dift`ereritthan A' 'iicant° <br /> Name(Organization or Entity) Contact Person Title <br /> Mailing Address City State Postal Code <br /> E-mail address Telephone Number(include area code) Fax Number(include area code) <br /> Sectlgn 3 ,Qtfiee.Gontact liiiormatiun check oris >, <br /> Consultant or Plan Preparer XContractor ❑Agent ❑Other If Other,specify: <br /> Name(Organization or tity) Contact Person Title <br /> /rl LTO tJ E/c%FE /V/C-TLry✓ 6, l� e T�rJS%c� <br /> Mailing Address City State Postal Code <br /> �� N, 41 ±5--!a57 tp <br /> -mail ddress Tele h- e Number(include area code) Fax Number(include area code) <br /> �` A 7�3 � _ 5s �• . <br /> Sectiorlr Pro ecC or Slfe Localioti <br /> Site Name(if any) County Municipality <br /> .CoT/ cnption v e- <br /> Location A dress/Des <br /> 7 E` El City ❑Village 'Township <br /> 5 r`7 PL:4 <br /> Section S.1ocatloil information' <br /> Create a map depicting the perimeter of the construction site(land disturbance)and relationship to nearby water <br /> resources using the Surface Water Data Viewer htto://dnr.wi.gov/om[water/data viewer.htm or a 7.5-minute series <br /> topographic map.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 'Town ship= Range ' Directlloni If this site is not wholly contained <br /> ❑ NW NE NW Op NE on the quarter-quarter section, <br /> S 3� N ow <br /> more description: <br /> El SW El SE ❑ SW ❑SE D <br />