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�P- No <br /> State of iiofN n ' Water Resources Application for Project Permits <br /> Depadme,t of Natural Resources F Form 3500-053 <br /> dnr.wigo% 5/, (R 08109 Page 1 <br /> Use this form for(check all that apply): ,' ? Notice: This form is used to apply for coverage under the <br /> �� state construction site stone water runoff general permit, <br /> Work In public waters(DNR—ch. 30, Wis. St a and to apply for a state or federal permit or certification for <br /> Work in waters of the U.S (Corps of Engineers) ✓O waterway and wetland projects or dam projects. This <br /> application form is authorized by chs 30 and 31,Wis.Stats, <br /> ❑ Permi:for Wetland Fill (DNR or Corps of Engineers for Alterations to Public Waterways,ch.281,Wis.Stats,for <br /> Wetland Fill and s.283.33,Wis.Stats.,for Storm Water <br /> ❑Storm water NOI—New land disturbing construction activity Discharges. Personally identifiable information on this form <br /> ❑Storm water NOI—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 forth <br /> Read all i1structions 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 1:Applicant Information <br /> plicant Name(indJ',v., Org. or Entity) Authorized Representative Title <br /> � rk, n5 9Ar <br /> Mailing Address City State Postal Code <br /> S1901park S-Free;� Uir\1 1 59830 <br /> E-mail address Telephone Number(include area code) Fax Number(include area code) <br /> ark{MS@Cen414r I , ne.-} '1IS - gbh 4898 S1me, <br /> Section 2: Landowner Information if different than Applicant) <br /> Name (Organization or Entity) Contact Person Title <br /> Some_ <br /> Mailing Address City State Postai 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 ❑ Other If Other, specify: <br /> Name (Organization or Entity) Contact Person YY,, Title <br /> BAisart� Lcindsea i h Gr re S+hi '2iAtc OLovrelr- <br /> Mailing Address City State Postal Code <br /> H"la Ave, fN-\; 1Ill+0LJJ n \A/--J- SJ13S <br /> E-mail address Telephone Number(include area code) Fax Number(include area code) <br /> 9Is- SBIA - 0 (0I P, <br /> Section 4: Project or Site Location <br /> Site Name(if any) ount- Municipality <br /> LocetionAdeas/gescr- 3knt ,e <br /> O� k I ct <br /> � OJ Ark S-+, bQh r &c 'J�,I,OLLrLa6_) ❑ city El village Tro <br /> wnship <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 http://dnr.wi.gov/oro/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 Survev S stem Method <br /> Quarter-Quarter I Quarter I Section I Townshin I Ran a I Direction if this site is not wholly contained <br /> ❑ NW ❑ NE ❑ NW ❑ NE ❑ E on the quarter-quarter section, <br /> 19 LID N 1 (o W more description: <br /> RSW ❑ SE T%SW [] SEXtSE 5et+sen, Lakes6ir-e Dr V. <br /> L <br /> oGk , LcrFs :zi as 3.3 <br /> I J � <br />