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State of Wisconsin RFC_eFW51 NRCS, DNR Wetland Restoration Activities <br /> Department of Natural Resourcesp� ^., <br /> -2011-W1 General Permit Packet R1-11 <br /> www.dnr.wi.gov -,. Form 3500-110 (05/2011)page 3 of 9 <br /> Notice:This application form is required under Section 3✓1s.Statsand ch.NR 310,Wis.Adm.Code or 30.026,Wis.Stats.Failure to submit a complete <br /> application to the Department may result in forfeitures or othe ZW2r�rcement.Personally identifiable information included on this form will be used to <br /> contact you and is not intended to be used for other purposes.It rfn J made available to requesters under Wisconsin's Open Records law[ss.19.31-19.39, <br /> Wis.Stats.] <br /> Section I: Landowner Information <br /> For projects that involve multiple landowners,please attach additional landowner names and contact information. <br /> Name Contact Person <br /> IMI N KR BiZ1010 OSt t_Ot,J <br /> Mailing Address Email Address _ - <br /> ao•433 (IMP ATIZA,)TS rio-n , Kclo JC Fieer. LKtr1 <br /> City S Pho r Fax _ <br /> L.141�cv i��� ( -D� - �3 - A50W- _ N I A <br /> Section II:Wetland Conser cti iesst ose <br /> Pk IK' IN <br /> Please®all proposed activities for this project and indicate the number of each activity type to the right.The attached maps,photos or plans should show <br /> the location of each activity type.Note:If dams are proposed,please also complete Section IV. <br /> RO SfD ACTIVITY 3 ". an.m.n,r © PROPOSED ACTIVITY: (ter m.mr <br /> Scrape Li El —Existing Wetland Acres Enhanced S <br /> Embankment/Dike(considered dams if placed —Wetland Acres Re-established <br /> across a watercourse) 3 S <br /> Micro-Topography ❑ —Wetland Acres Created <br /> Breach Dike or Dike Removal(circlewhich applies) EI Existing Wetland Filled(i.e.for berm,dike,embankment <br /> not across a watercourse) <br /> ❑ Dams or Water Control Structure Across a Drain rile Breaks <br /> WaterCoUrse Dams(i.e.weirs,tin whisteles,ditch <br /> plugs with outlet pipes) <br /> ElDitch Fill/Ditch Plug(ditch plugs must have no El Other Activity(Please describe): <br /> outlet pipes) <br /> Section III:Agent Information <br /> Note:DNR Water Management Specialists should send all correspondence directly to agent and applicant. <br /> Check®if applicable: ���� Business/Agency V S F WS <br /> El Consultant ❑Contractor tld"Authorized Representative ST - CRoIy V_$''t LA°'9 MANnc�f+�YN T D15TR1c <br /> Contact Person E-mail Address <br /> (,AiTI-IN SMttFt CA'I-ru0 — SnatrN �T— <br /> Mailing Address <br /> 177(9-1 5 V H S} <br /> City State Zip Phone Fax UTC <br /> t.)4u w <br /> (ZICt1MoND ( �Is ) a�e- <br /> Section IV: Site Information <br /> Project Address Waterway Name <br /> SIR <br /> OQ O season rw.�sn�a Rangge OCity pXTTowCn IOVillage County a �` <br /> '� I Se�. 03 JOf� 1Cj� 1-ao . V*r-L VI,(�IVi.'.7Tr <br /> Start Date(Month/Day/Year): Project End Date/(Month/Day/Year): <br /> iC� S I I sort 11 � I l o-lotl <br />