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State of Wisconsin /' C(cl�i V Water Resources Application for Project Permits <br /> Department of Natural Resources Q 9vG FQ Form 3500-053(R 08109) Page 1 <br /> dnr.wi.gov / of7-0. <br /> Use this form for(check all that apply): �p Notice: This forth is used to apply for coverage under the <br /> state construction site storm water runoff general permit, <br /> ElWork in public waters(DNR—ch. 30,Ws.Stta and to apply for a state or federal permit or certification for <br /> F1Work in Waters of the U.S(Corps of Engineers) waterway and wetland projects or dam projects. This <br /> application form is authorized by chs 30 and 31,Ms.Stats, <br /> for Alterations to Public Waterways,ch.281,Ws.Stats,for <br /> ❑ Permit for Wetland Fill(DNR or Corps of Engineers) Wetland Fill and s.283.33,Wis.Stats.,for Storm Water <br /> ❑ Storm water NOI—New land disturbing construction activity Discharges. Personally identifiable information on this form <br /> ❑Storm water NO[—Renewal FIN# may be used for other program purposes and may be made <br /> ❑Dam projects(DNR or Corps of Engineers) available to requestoms under Wisconsin's Public Records <br /> laws and be posted on the Department website. This form <br /> Read all instructions provided before completing. If additionaland any required attachments constitute the permit <br /> space is needed,attach additional pages. application.Failure to complete and submit this application <br /> forth may result in a fine and/or imprisonment or forfeiture <br /> under the provisions of applicable laws. <br /> Section 1:Applicant Information <br /> Applicant Name(Indiv.,Ong.or Entity) Authorized Representative Title <br /> OMPIT- 0 <br /> Mailing Address City State Postal C e <br /> Incl ► ENE �sAr/Tf m -6-;5D <br /> E-mail address Telephone Number(include area code) Fax Number(include area code) <br /> lItflG ho& tnSY1 ,coM oZo21 24. 8.S <br /> Section 2: Landowner Information if different than Applicant) <br /> Name(Organization or Entity) Contact Person Title <br /> Mailing Address City State Postal Code <br /> E-mail address Telephone Number(include area code) Fax Number(include area code) <br /> Section 3: Other Contact Information check one): <br /> ❑Consultant or Plan Preparer ❑Contractor ❑Agent ❑Other If Other,specify: <br /> Name(Organization or Entity) Contact Person Title <br /> Mailing Address City State Postal Code <br /> E-mail address Telephone Number(include area code) Fax Number(include area code) <br /> Section 4: Project or Site Location <br /> Site Name(if any) County Municipality <br /> 19 u i-he7�t— <br /> Location Address/DescriptionE]City ❑Village WTownship <br /> g�20 <br /> Corcoran Rd1.l. wnfiw Wester <br /> Section 5: Location Information <br /> Create a map depicting the perimeter of the construction site(land disturbance)and relationship to nearby water <br /> resources using the Surface Water Data Viewer httD7/idnr,vvi.(zov/org/wateridata viewer.hrm or a 7.5-minute series <br /> topographic map You can print the map and then draw the location on the map. <br /> Provide the section range township information and if available the Latitude and Longitude information. <br /> PLSS Public Land Survey System)Method <br /> Quarter-Quarter Quarter Section I Township Range I Direction I if this site is not wholly contained <br /> ❑ NW ❑NE ❑NW ❑NE E on the quarter-quarter section, <br /> 3> Lb N 7 W more description: <br /> El SW El SE ❑SW ❑SE V� <br /> -r6— IP�,.es , t� l �z, elak 2, m-r 50 X �, <br /> t4 af L6t 1, Block Z. <br /> (QGL 0-5&- Q100 -02-900) <br /> I <br />