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Waterway General Permit Application and Approval <br /> Form 3500-108 (R 5/05) Page 4 of 4 <br /> Section X: Certification and Permission <br /> I am the owner of the riparian property or am the duly authorized representative and may sign this application on behalf of the owner(s)of said <br /> property. I hereby certify that the information contained herein is true and accurate. I have read and understand all of the conditions listed in <br /> this permit and in the Instructions. I have designed the project to comply with the conditions,and I will construct the above-mentioned project <br /> in compliance with all such conditions. I hereby give the Department permission to enter and inspect the site at reasonable times,to evaluate <br /> this application and to monitor compliance with any resulting permit. I understand that failure to comply with any or all of the provisions of the <br /> permit renders the authorization contained herein null and void and may result in a fine and/or imprisonment or forfeiture under the provisions <br /> of ch.30,Wis.Stats. <br /> Landowner or Agent Printed N e <br /> G L I <br /> Landowner A Agent Date Signed <br /> V V <br /> Mail this s ned,completed form,along with photos,plans,completed Fact Sheet(Form 3500-53A and appl tion fee to the <br /> appropria Department of Natural Resources office in the region where the project is located.See the instructions for regional office <br /> addresses. <br /> This permit application is approved when it is signed and dated below by an authorized Department of Natural Resources employee. <br /> Section XI: Permit Approval (Leave Blank-DNR Use Only) <br /> Date. plication Received Docket# ale Application Complete ee Received <br /> 6 - o- . - Le -ZN -o q $ Go -Oct <br /> LA NHI Checked? HIYJ <br /> istoric Checked? ASNRI? E]Yes No PRF? ❑Yes LJ No PNW? LJYes 2 N <br /> STATE OF WISCONSIN,DEPARTMENT OF NATURAL RESOURCES Title <br /> For the relary <br /> Iss d By Dale Si ed <br /> 6 �o <br /> Copies of this permit sent to: Conservation Warden $PA I' <br /> U.S.Army Corps ofEnginbers 134trCriTa5M <br /> County Zoning Administrator Rct,n h; 5a,/ 7in� <br /> Ce. +-)-4C+av-,. Satin <br />