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Stat <br /> of <br /> Department tmeitofN n Waterway General Permit Application and Approval <br /> Department of Natural Resources <br /> PO Box 7921,Madison WI 53707-7921 Form 3500.108 (R 5/05) Page 1 of 4 <br /> dnr.wi.gov <br /> Notice:This application form is required under Section 30.206,Ws.Stats.and ch.NR 310,Wis.Adm.Code. Failure to submit a complete application to the <br /> Department at least 35 days prior to the date of proposed construction may result in dismissal of your application,forfeitures or other enforcement. Personally <br /> identifiable information included on this form will be used to contact you and is not intended to be used for other purposes. It may be made available to <br /> requesters under Wisconsin's Open Records law[ss. 19.31-19.39,Wis.Stats.]. <br /> Section I: Activity Gr_M1).E00q--- r - 03 fri L7 <br /> Check the box(es)next to the type of General Permit you are requesting with this application: <br /> ❑Biological Shore Erosion Control ❑Dry Fire Hydrant ❑Pilings ❑Seawall Replacement <br /> ❑Boat Ramp ❑Fish Habitat Structure ❑Pond—Landscape ❑Seawall-Replace with Riprap <br /> ❑Clear Span Bridge ❑Ford ❑Pond—Stormwater ❑Weed Rake <br /> ❑Culvert ❑Grading—Less Than One Acre ❑Pond—Wildlife ❑Wildlife Habitat Structure <br /> ❑Dredging—Drainage District ❑Grading—One Acre or More ❑Riprap ❑Other: <br /> ❑Dredging-Utility Crossings ❑Intake/Outfall Structure ®Riprap Repair/Replacement <br /> When completing this application,follow the specific instructions for the type of General Permit you are applying for. Instructions can be obtained on our website <br /> at dnr.wl.gov under the topic"Waterway and Wetland Permits",or from your local DNR Service Center. <br /> Section ll: Landowner Information <br /> Name Contact Person <br /> J01 ii J "m pj i Q r <br /> Mailing Address Email Addre s <br /> A16- 6;�b ,/9W Allam f 60 f i eho. cor-) <br /> City tate IP Code ha <br /> Number(include are de ax Number <br /> aRc,� rev iV bo `} b�S- 0 <br /> Section III: Agent Information(Consultant,Contractor,or Authorized Representative) <br /> Name Contact Person <br /> Mailing Address Email Address <br /> City'f tate IP Code elep one Number(include area code ax Number <br /> V 1/"-Q.��:-- 3 �7i <br /> Section IV: Site Information / <br /> Local Address / N aterway Name <br /> a9�30 - D <br /> ✓h J,ntr �- <br /> '/. 1'/. ection ownship an e E Ey <br /> oun <br /> s(!t, 5 G 1 N �l ❑City L�`Town ❑Village of ��I S'� Eu,r <br /> Location Description VV <br /> el <br /> Section V: Additional Information <br /> Project Start Date(month/day/year) Approxi ate Pro'ect End Date (month/da ytyear) ate of Photographs <br /> k I �Z z m l og <br /> I have[nvestiga ed whether there are any wetlands at tri construction site or any wetlands that may ffected by El Yes <br /> N0 <br /> the project. <br /> Be aware that the Department shall,pursuant to ch.NR 103,Wis.Adm.Code,require that the project comply with the water <br /> quality standards provisions in ch. NR 103.The presence of wetlands may affect eligibility for this general permit. <br /> I have investigated whether there are any listed threatened or endangered species at the construction site. ❑yes VNO <br /> Be aware that the Department shall,pursuant to s.29.604(6r),Wis.Stats.,determine whether approval of a general permit <br /> may affect a listed threatened or endangered species.The presence of a listed threatened or endangered species may <br /> affect eligibility for this general permit. <br /> I have investigated whether there are any listed cultural or historical resources at the construction site. ❑Yes XNO <br /> Be aware that the Department shall,pursuant to s.44.40,Wis.Stats.,determine whether approval of a general permit may <br /> have an adverse affect upon historic property.The presence of historic property may affect eligibility for this general permit. <br /> If you checked"Yes"to any of these questions,submit supporting documents with your application. <br />