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Water Resources Application for Project Permits <br /> ^_ . '� �"� " Form 3500-053 R 08/09 Page 2 <br /> Applicant/Project Name' T O"J lun AAA4 y BAB County l3fl/Lr 0r7 <br /> Latitude and Longitude Method if available <br /> Degrees Minutes Seconds Method of Determining <br /> Latitude ❑ GPS <br /> Longitude ElDNR's Surface Water Data Viewer <br /> ❑Other(specify): <br /> Section 6:Waterways and Wetlands see Instructions about potential additional a lication requirements) <br /> Name(description if unnamed)of closest waterbodies Type Special status <br /> 81 � Ye i I nt u- Lq 6- N Lake ❑Stream ❑ ORW/ERW ❑303(d) listed <br /> Yes No Wetlands: <br /> ❑ 'M 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 /> FWetland Locator Tool [ISoils(NRCS maps) ❑ Other(specify) <br /> tt ://dnr.wi cov/wetlands/locatinc html <br /> Section 7: Pro ect Information Attach additional sheets as necessa <br /> Duration: Antic pated Project Start Date(month/day/year) Projected Project End Date(month/year) <br /> (vmv, kve- 2,01/ <br /> Photos: Provide photographs of the"before"condition Date of Photographs' a 0 0 8 <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. Qatraj W dt42 l- nam Gu2lx8,j T rd w r s!f Ta <br /> '�2l9PAyl2 o&rG NRi QjPILMB`/ IUA� AUA-,e) Ae6,6 3'7=3AJ�' <br /> ADOlK�ty, $o y Avg4J 2.0crc W <br /> Section 8:Attachments and Permit Access(Include appropriate attachments for each proposed activity.) <br /> The following attachments, together with this form, constitute this permit application: (include all that apply) <br /> Attachment Name(s) <br /> I have obtained a copy of the construction site storm water runoff general permit from the department's Internet site. <br /> t ://dncwi.00v/runoff/odf/stormwater/permits/construction/construction Permit S067831 3 odf <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 Telephone Number <br /> (�:Far 9ct.rrk1, h5 <br /> Signature Date SI ned <br /> LEAVE BLANK-AGENCY USE ONLY <br /> Date Received Fee Received Construction Site ID# Docket# Corps# <br /> Initial screening: <br /> ❑ Completeness ❑ Historic checked ❑ Rare species(NH I)checked ❑Wetlands checked <br />