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1 <br /> Water Resources Application for Project Permits <br /> Form 350,00--053 R 08/09 Page 2 <br /> Applicant/Project Name: j t'q County t_-t- <br /> Latitude and Longitude Method if available <br /> Degrees Minutes Seconds Method of Determining <br /> Latitude 4!� zJ� ❑ GPS <br /> Longitude ElDNR's Surface Water Data Viewer <br /> 9 Other(specify): Te rr Ue!- <br /> Section 6: Waterways and Wetlands see Instructions about potential additional apRlication requirements) <br /> NN7(descripti�CLon if unnamed)of closest waterbodies Type Special status <br /> I l S / l Lake ❑Stream ❑ORW/ERW ❑303(d) listed <br /> Yes No Wetlands: <br /> Wetlands 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 /> ❑Wisconsin Wetlands Inventory ❑Wetland Delineation(attach report) <br /> ❑Wetland Locator Tool ❑ Soils(NRCS maps) ❑ Other(specify) <br /> htt ://dnr.wi.00v/wetlandsfiocatino html <br /> Section 7: Pro ect Information Attach additional sheets as necessa <br /> Duration: Anticipated Project Start Date(month/day/year) Projected Project End Date(mordh/year) <br /> U -1 — I -� 11 S -f)l - -�6j/ <br /> Photos: Provide photographs of the"before"condition Date of Photographs STI Ar n a 0 <br /> Narrative of the Project: <br /> Provide a one to two paragraph description of the proposed project, including land and water alterations and intended <br /> use(s)of the project. <br /> See- xM ¢. , <br /> Section 8:Attachments and Permit Access (Include appropriate attachments for each proposed activity.) <br /> The following attachm is together with this form, constitute this permit application: (include all th t apply) <br /> nnAtttachmer Name(s)�pip PAA )Ix 1 r yt C k -Qq) (T( 6.i„S (aj <br /> tv (J�Grn2lUtU <br /> I have obtained a copy of the construction site storm water runoff general permit from the department's W met site. <br /> htto:fldnr W aov/runoff/odf/stomiwater/permits/construction/construction permit S067831-3 odf <br /> Section 8: Certification&Permission <br /> Certification: I hereby certify that I am the owner or authorized representative of the owner of the property which is the <br /> subject of this Permit Application. I certify that the information contained in this form and attachments is true and <br /> accurate. I understand that failure to comply with any or all of the provisions of the permit may result in permit revocation <br /> 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 <br /> this notice and application, and to determine compliance with any resulting permit coverage. <br /> Name of 0 er/Authorized Representative(Print or Type) T' a Telephone Number <br /> 6 e `7 b3-S 3 26 <br /> Signat Date Signed <br /> LEA BLANK-AGENCY USE LY <br /> Date Received Fee Received Construction Site ID# I Docket# 4 P- Corps# <br /> (P - 11 — Zoll $ Sb .00 �ntr_-r_ nxla <br /> I_5al screening: �� ,_,,/ <br /> Completeness [Historic checked 'Rare species(NHI)checked 2.0 etiands checked <br />