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State of Wisconsin FWS, NRCS, DNR Wetland Restoration Activities <br /> Department of Natural Resources WRGP-2011-WI General Permit Packet Fill-11 <br /> www.dnr.wi.gov (05/2011)page 4 of 9 <br /> Section V: NRCS/FWS/DNR Restoration Project Self Certification Form ��(` <br /> Notice:Pursuamtothe Memorandum of Agreement(MOA)betweenWDNR,FWS,ACOE and NRCS,Icertifythat the following items have been reviewedforcorn li ce <br /> with NRCS Practice Standards 378,410,638 and 657,which can be found at http://efotg.nres.usda.govltrmmenuFS.aspx.and also with7fyplicablesQte regul //� <br /> and all relevant supporting documentation is located in the project file.—if dam is involved,dam owner is primary landowner. GJ `��` ! n <br /> Office address uSFL,%S - 5T . CRCIX WZTI_P^J1) Telephone 6° L% <br /> 0At JAC75'W WT 'DIST0kC'-t' _+15 - Aqu- 7'8y SC/ eplJ <br /> 1 r th V w 1 5qO IT I <br /> Sig ure NamuH- Agenc Date <br /> 3,3 <br /> Primary Landowner" C ree :CS)or its Name I.D.(FWS) <br /> AV$R[{4N Y/t$Cos'1 F STORE ?cRATlot1l <br /> Additional Landowners Signatory to the Project(Co-Applicants) <br /> Q ELIGIBILITY STANDARDS <br /> Notice:l certify the proposed wetland restoration project meets all the following eligibility standards and is in compliance with all terms and <br /> conditions of WRGP-2011-WI and that all relevant supporting documentation is located in the project file available upon request <br /> Note:For words in italics,please use the definitions in Section VIIII. <br /> NRCS,FWS or DNR are the project sponsor for the wetland restoration project.For wetland projects conducted <br /> on private lands,the project sponsor(NRCS,FWS)have obtained a binding wetland conservation project <br /> agreement with the landowner(s). <br /> 2. Project purpose is for wetland conservation that will result in the re-establishment of drained wetlands, <br /> enhancement of existing degraded wetlands or creation of new wetlands. <br /> ( 3 Project will result in net gains to wetland functions and will not result in a net loss of existing wetland acreage. <br /> LJ For example,if the project places fill into an existing wetland,there must be a gain in at least the same <br /> amount of wetland as the existing wetland acreage lost due to filling. When assessing wetland functional <br /> values use the Wisconsin Rapid Assessment Methodology found at http://dnr.wi.gov/wetlands/documents/ <br /> RapidWetlandAssessment.pdf. <br /> 4. NRCS,FWS or DNR has documented site conditions showing impacts to topography,soils,native vegetation or <br /> hydrology that has degraded the wetland and are potentially reversible with wetland conservation activities. <br /> 5. Project involves only the following wetland restoration activities that are designed,and will be constructed,to <br /> meet the following applicable Natural Resources Conservation Service Field Office Technical Guide Standard <br /> Conservation Practice 378-Pond(7/01),41 0-Gracle Stabilization Structure(7/01),638-Water&Sediment Control <br /> Basin(7/01)and 657-Wetland Restoration(9/00)found at http://efotg.sc.egovusda.gov/treemenuFS.aspx in <br /> Section IV in the Conservation Practices folder. <br /> Hydrology Alterations including drain tile removal,filling of ditches,dam or water control structure construction,pump <br /> removal,breaching structures,re-routing artificial drainage features or manipulation of water control structures. <br /> Soil Disturbing Activities including removal of soil and vegetation or creating micro-topography including shallow wetland <br /> scrapes,channels,submerged islands and interconnected open water areas. <br /> Plant Management Activities including introducing plants by planting,cultivating,stocking or releasing,controlling plants <br /> by cutting,destroying or suppressing using manual or mechanical methods,introducing United States Department of <br /> Agriculture approved biological agents,manipulating water levels,burning,or using United States Environmental Protection <br /> Agency registered herbicides and chemicals applied according to the label instructions. <br /> Monitoring Activities including installing and maintaining devices such as staff gauges,water level recording devices,small <br /> weirs and flumes whose purpose is to measure and record scientific data for monitoring of the conservation activity,periodic <br /> water quality testing and periodic sampling to show changes in the flora and fauna composition and abundance. <br />