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State of Wisconsin U.S.Army Corps of Engineers-St.Paul District STATE/FEDERAL APPLICATION <br /> Department of Natural Resources Regulatory Functions FOR WATER REGULATORY <br /> (Return to appropriate 190 Fifth Street East PERMITS AND APPROVALS <br /> DNR District/Area Office) St.Paul,Minnesota 55101-1638 Form 3500-53 Rev.9-95 <br /> PLEASE COMPLETE BOTH PAGES 1 &2 OF THIS APPLICATION. PRINT OR TYPE.Use of this form is required by the Department for any <br /> application filed pursuant to Chapter 30,Wis.Stats. The Department will not consider your application unless you complete and submit this <br /> application form. Personally identifiable information on this form is not intended to be used for any other purpose. <br /> 1. Applicant(Individual or corporate name) 2. Agent/Contractor(firm name) <br /> N MAS 1 r R tbWR 1^ iW_ _ <br /> Address Address <br /> OL r-. Z-1(0,12- tAwy 35 <br /> City,State,Zip Code Number City,State,Zip Code <br /> 57 We13SirpL WE 5-11M 3 <br /> Telephone No.(Include area code) Tax Parcel Number Telephone No.(Include area code) <br /> 11S - 'lr5-Roto- z <br /> 3. If applicant is not owner of the property where the proposed activity will be conducted,provide name and address of owner and include <br /> letter of authorization from owner. Owner must be the applicant or coapplicant for structure,diversion and channel change activities. <br /> A purchaser under a land contract is not considered a riparian owner until property transfer has occurred. <br /> Owners Name Address City,State,Zip Code <br /> V X1171 G <br /> 4. Is the applicant a business? ❑Yes [0 No 5. Project Location <br /> If YES,is the permit or approval you are applying for <br /> Address <br /> necessary for you to conduct this business in the State <br /> of Wisconsin? El Yes ❑No Village/City/Town <br /> If YES,please explain why(attach additional sheets if Waterway V C,2 <br /> necessary): <br /> County <br /> Govt.Lot_ OR &�_1/4.C1/4,of section r <br /> Township North,Range /7 (East)(West) <br /> 6. Adjoining Riparian(Neighboring Waterfront Property Owner)Information <br /> Name of Riparian#1 N Address City,State,Zip Code <br /> F4 <br /> Name of Riparian#2 Address City,State,Zip Code <br /> N A <br /> 7. Project Information(Attach additional sheets if necessary) <br /> (a)Describe proposed activity(include how this project will be constructed) <br /> (b)Purpose,need and intended use of project <br /> (c)I have applied for or received permits from the following agencies: (Check J) <br /> [IMunicipal F�[ County M Wis.DNR ❑ Corps of Engineers <br /> (d)Date activity will begin if permit is issued Z' 7-6-18;be completed: 3 W Y6 <br /> (e)Is any portion of the requested project now complete? <br /> If yes,identify the completed portion on the enclosed drawings <br /> ❑ Yes 4 D No and indicate here the date activity was completed: <br /> I hereby certify that the information contained herein is true and accurate. I also certify that I am entitled to apply for a permit,or that I am <br /> the duly authorized representative or agent of an applicant who is entitled to apply for a permit. Any inaccurate information submitted may <br /> result in permit revocation,the imposition of a forfeiture(s)and requirement of restoration. <br /> Signature of Applicant(s)or Duly Au 'zeQ Agent Date Signed <br /> Z- 23 R <br /> il AAGENCY <br /> Corps of Engineers Process No. Wisconsin DNR File No. <br /> Received By Date Received Date Application Was Complete <br />