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_ L,.'v't:9i ` hS4NOI012.i' . •-4�fi4 ri� `'L.k M ' n•5 �"l vi •i.:.._nHGL P"G.* .Fiu-ci•`�.-_�m9}; r%2 r�ii.n n: .i.,��.�i!l+:,x t is g '- T x. <br />R�PL '@f=M€VT�OF�+Ee J-ST G NAU�GpBL�STjRE'A.iVI;CULVERT �'�E3XEMPT,�®IV, [I IFORM'A+Ti.Q f, R_C®RDS <br />Thswor s eetc n�bedreq ns an eono r RIP n�ercha te, t171�23' a rs p %)f ; a ojad�f�luernai to o ce pr+ob errls,.at dfordad ,� <br />'. n4 <br />versel�rxnpaetst �treb , r - "��k' <br />Project Name: <br />�I I krzrz Imo. • %�. � rhv�,� L.rtik� <br />Existing Road <br />Proposed Road <br />Culvert size <br />fz <br />iZ <br />Culvert length <br />1 <br />+ <br />Road top width <br />(surface +shoulders) <br />Road shoulder side slopes <br />(I e. 2:1 or 3:1 slopes) <br />Describe changes to culvert <br />elevation or slope. <br />_ �, ; i, inn <br />q .. <br />' Yes No <br />Will the road surface eleva'' <br />tion over the culverts be�_� <br />raised? <br />x <br />Mark the appropriate box below if any of the following problems exist at the current culvert <br />The culvert is perched above the streambed (i.e. waterfall at the outlet) <br />There is a scour pool at the outlet <br />There is water pooling on the upstream side of the road <br />Water can overtop the road during flood events <br />The culvert can get blocked with debris'or there are beaver problems <br />Completion of this Information Worksheet will provide the WDNR with information to evaluate the proposed project. The Department will review the <br />project proposal and site specific conditions to determine if the project is exempt from DNR culvert replacement permits. Depending an specific site condi- <br />tions, your liaison may request further information. It is the applicant's responsibility to obtain all necessary local, state and federal permits and approv- <br />olsfrom the appropriate entities prior to construction. By signing below you are acknowledging that you have read this information and understand that <br />further reviews may be needed to proceed with your project. The signer of this document is acknowledging they have the authority to represent the con- <br />structing municipality. <br />Signature & Title Date / 7__ <br />-i <br />