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W-N0-?01q - 7-00 / P-7 <br /> Stale of Wisconsin Water Resources Application for Project Permits <br /> Department of Natural Resources <br /> tlncwi.gov Form 3500-053 (R 8113) Page 1 of 3 <br /> Notice: Pursuant to chs.30 and 31,Wis.Stats.,ch.281,Wis.Slats, and s.283.33,Wis.Stats.,this form is used to apply for coverage <br /> under the state construction site storm water runoff general permit,and to apply for a state or federal permit or codification for waterway <br /> and wetland projects of dam projects.This form and any required attachments constitute the permit application. Failure to complete and <br /> submit this application form may result in a fine andfor imprisonment or forfeiture under the provisions of applicable laws including <br /> s.283.91,Wis.Stats. Personal information collected will be used for administrative purposes and may be provided to requesters to the <br /> extent required by Wisconsin's Public Records Laws(ss. 19.31-19.39,Wis.Stats.). <br /> Use this form for(select all that apply): <br /> Waterway General Permit ❑ Storm water NOI-New land disturbing construction activity t(fCC <br /> ❑ Waterway Individual Permit ❑ Storm water NOI-Renewal FIN# ✓,Q �I/ . <br /> ❑ Welland General Permit ❑ Work in waters of the U.S.(Army Corps of Engineers) f5 I�- <br /> ❑ Wetland Individual Permit ❑ Dam projects(DNR-ch.31,Wis. Stats.,or Army Corps of EngiRee a)1p>>T <br /> Read all instructions provided before completing. If additional space is needed,attach additional pages. ��In <br /> Section 1: Landowner Information <br /> Landowner Name(first and last name,org.or entity) Authorized Representative <br /> Tim Heuer Paul Cook- Burnett County LWCD <br /> Mailing Address City Slate ZIP Code <br /> 12313 22nd St. North Lake Elmo I MN 55042 <br /> Email Address Phone Number(include area code) Alternate Phone Number <br /> (612)990-0268 <br /> nt Information 93 Select It same as land�er <br /> Applicant Name (first and last name,org.or entity) Contact Person <br /> Mailing Address City State ZIP Code <br /> Email Address Phone Number(include area code) Alternate Phone Number <br /> 'Section 3: Primary Project Contact 0 Select if same as landowner <br /> Q Consultant Q Contractor (j)Other - Specify: Burnett County Land and Water Conservation <br /> Name(Intl., Org.or Entity) Contact Person(first and last name) <br /> Bnmetl County Land and Water Conservation Dept. Paul Cook <br /> Mailing Address City StateZIP Code <br /> 7410 County Road K #109 Siren WI 54872 <br /> Email Address Phone Number(include area code) Alternate Phone Number <br /> pcook@bumetteoty.org (715) 349-2186 (715)497-6755 <br /> SIctlon 4 Project or Site Location <br /> Project Name Coun <br /> ty Q City Q. Town Q Village <br /> fish Sticks Bumett of Jackson <br /> Location Address/Description / IA <br /> 3893 Mallard lake Rd. a7-01a-g-7V-�S-3j-rj-0j-059-b,D-7000 <br /> Public Land Survey System RLSS)-Provide the section,range,township information and latitude and longitude in decimal degrees,if available. <br /> SE /.of SE '/.of Section 35 Township 40 N. RangeIS OE <br /> Late Longitude <br /> If this site is not wholly contained in the quarter-quarter section, more description: <br />