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Water Resources Application for Project Permits <br /> Form 3500-053 R 0=9 Pae 2 <br /> Applicant/Project Name: countyy.rne7tT <br /> Latitude and Longitude Method if available <br /> Degrees Minutes Seconds Method of Determining <br /> Latitude ❑GPS <br /> ❑DNR's Surface Water Data Viewer <br /> Longitude ❑Other(specify): <br /> Section 6:Waterways and Wetlands see Instructions about potential additional apRlication requirements) <br /> Name(description if unnamed)of dosest waterbodies Type Special status <br /> 7 <br /> gt e I(o w "ke- Lake ❑Stream ❑ORW/ERW ❑303(d) listed <br /> Yes No Wetlands: <br /> ❑ <br /> 29 Wetlands will be filled excavated or disturbed during construction or as part of this project. <br /> The presence of wetlands has been evaluated using: (check all that apply) <br /> ❑Wisconsin Wetlands Inventory ❑Wetland Delineation(attach report) <br /> ❑Wetland Locator Tool ❑ Soils(NRCS maps) ❑Other(specify) <br /> =:/Idnr.wi.gov/wetiands/locabnq.htm( <br /> Section 7: Project Information Attach additional sheets as necessary) <br /> Duration: Anticipat Proj Start Date(month/daylyear) Projected Project End Date(month/year) <br /> I A 69/0 11 1 6910,7111 <br /> Photos: Provide photographs of the"before"condition. Date of Photograhs: g I I I <br /> Narrative of the Project: <br /> Provide a one to two paragraph description of the proposed project, including land and water alterations and intended <br /> use(s)of the project. P1o.ct b"-2!}" 'PLe_)a s}av�L oV-r --Riter1sx-brec -tp -ovtv-al 3hoVe Zvx-_ <br /> �tostcsn. Wtl\ Sc%ed o_kbeU�e- k r&LN y' "k vx- r Imax togv�\ V'0zh"k- KO-YL-r^'.vcistlw <br /> diction a:Attachments and Permit Access(Include appropriate attachments for each proposed activity.) <br /> The following attachments,together with this form,constitute this permit application: (include all that apply) <br /> AttachmentName(s) Fe_eAprUc_' 3���053A ! PRrvh.rA�plic `1'• ckst A'jhn-IiPvn+ <br /> I have obtained a copy of the construction site storm water runoff general permit from the department's Internet site. <br /> htto://dnr.wi.00v/runoff/Ddf/stormwater/permits/construction/construction permit S067831-3 odf <br /> Section 9: Certification&Permission <br /> Certification: I hereby certify that 1 am the owner or authorized representative of the owner of the property which is the <br /> subject of this Permit Application. 1 certify that the information contained in this form and attachments is true and <br /> accurate. I understand that failure to comply with any or all of the provisions of the permit may result in permit revocation <br /> and a fine and/or imprisonment or forfeiture under the provisions of applicable laws. <br /> Permission: i hereby give the Department permission to enter and inspect the property at reasonable times, to evaluate <br /> this notice and application,and to determine compliance with any resulting permit coverage. <br /> Name of Owner/Authorized Representative(Print or Type) Title Telephone Number <br /> 7_45IAX+ V\n 0Whex- <br /> S' t <br /> x- <br /> Signatur Date Signpd <br /> LEAVE BLANK-AGENCY USE ONLY <br /> Date Received Fee ReceivedConstruction Site ID# Docket#C 0.No- Corps# <br /> T -L4 - ZO I i raoN-n - 09'4z4 <br /> MIniti screening: <br /> Completeness 214istoric checked ETkere species(NHI)checked @ WeUands checked <br />