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Water Resources Application for Project Permits <br /> Form 3500-053 R 08109 Pae 2 <br /> Applicant/Project Name: y r t v County <br /> J <br /> Latitude and Longitude Method if available <br /> Degrees Minutes Seconds - <br /> I r- Method of Determining <br /> Latitude d ��i 3�/i ❑ GPS <br /> ❑ DNR's Surface Water Data Viewer <br /> Longitude �2 ° �' QOther(specify): <br /> s7 <br /> Section 6:Waterways and Wetlands see Instructions about potential additional application requirements) <br /> Name(description if unnamed)of closest waterbodies I Type Special status <br /> AS h b.�, 2<ake ❑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 /> http://dnr.wi.gov/wtagggaagggting.html <br /> Section 7: Project Information Attach additional sheets as necessary <br /> Duration: Anticipated Project Start D to(monthlday/year) Projected Project End Date(month/year) <br /> Photos: Provide photographs of the"before'condition Date of Photographs: <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.=NsiL�/ Q• r,A&�„n r..�a, 1^e,c.F oh SG /�.�.e. (ye,( )�, �'c,,,� b�. K�`.G•�aWU <br /> F'k s� nip-" f <br /> Section 8: Attachments and Permit Access (Include appropriate attachments for each proposed activity.) <br /> The following attachments, together wit this form, constitute this permit application: include all that apply) <br /> Pu <br /> Attachment Name(s) y- (Joy'Llfr ¢ AZI ` <br /> LIn I have obtained a copy of the construction site storm water runoff general permit from the department's Internet site. <br /> httU://dnr.wi.ciovirunoff/Ddf/stormwater/permits/construction/construction permit 5067831-3 pdf <br /> *Section 9: 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 Owner/Authorized Representative (Print or Type) Title - T I phone Number <br /> f EKE--rj N pt-so LA-tJ D b7 3o 5-al -7e)06 <br /> Signature Date Signed <br /> V-a-J <br /> LEAVE BLANK-AGENCY USE ONLY <br /> Date Received Fee Received Construction Site ID# Docket# Corps# <br /> Initial screening: <br /> 0 Completeness ❑ Historic checked ❑ Rare species(NHI) checked ❑Wgtlands checked <br />