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��- na8a -i� i sos-ooao!a,vod �vP - PDO -o -7-0 � 3� <br /> State of Wisconsin &ate so es Application for Project Permits <br /> Department of Natural Resources r� L� Form 3500-053(R 08/09) Page 1 <br /> dnr.wi.gov � <br /> Use this forth for(check all that apply): NotiiAThi�m <br /> r �used to apply for coverage under the <br /> state c' ruction site stone water runoff general permit, <br /> ❑Work in-public waters (DNR—ch. 30, Wis. Stats.) and to a for a state or federal permit or certification for <br /> ❑Work in waters of the U.S (Corps of Engineers) waterway RM 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 NO —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 /> form may result in a fine and/or imprisonment or forfeiture <br /> under the provisions of applicable laws. <br /> Section 1Applicant Information <br /> jAyplicant Name (Indiv., Or . o Entity) Aut orized Representative Title C� <br /> Maili A r / Clty / 0 State Postal Code <br /> E-mail address n xJ Telephotn/ umber(include area code) Fax Numbe In de area code <br /> T S (�iC ) 1L .n -55 Wlo -7L3- - /o� <br /> Section 2: La downer Information if tlifferent than Applicant) <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 /> Section 3: Other Contact Information check one): <br /> ❑Consultant or Plan Preparer ❑ Contractor ❑Agent [j/]Other If Other,hospecify: d 0 <br /> Name(Organization or Entity) Contact Person Title C <br /> J_e%ted " S <br /> M iling Address Cit State Postal Code <br /> wtr oleS rJ L wu M� 53 <br /> E-mail address Tela ne Number(include area code) Fax Number(include area code) <br /> . TSS t e CtI dyv�'_ 7 S-0 D <br /> %Section 4: Project or Site Loc ion <br /> Site Name (if any Countynicpality <br /> Feopkg ' I-Bwl n <br /> Location A s escription <br /> [I City ❑Village �Township <br /> Section 5: Location 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 http7//dnr.vA.gov/org/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 Township Range I Direction If this site is not wholly contained <br /> [A NW ❑ NE [A NW ❑ NE ^ on the quarter-quarter section, <br /> ❑ SW USE ❑ SW ❑SE <br /> L+ N ` !� W more description: <br /> +`tel <br /> SE Nfw <br />