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�6CIFIVFD Gf No-a© 7-OSs�3 <br /> State t Wisconsin Water Resources Application for <br /> Department of Natural Resources <br /> dnr.wi.gov j((p NOV 2 9 201 Project Permits <br /> b/VRI K Fonn 3500-053 (R9,12) <br /> SUPERIpR D-'7-oao-�9�a-lto <br /> Notice: Pursuant to chs.30 and 31,Wis.Stats.,ch.281,Wis.Stats, and s.283.33,Wis.Stats.,this form is used to apply for coverage under <br /> the state construction site stone water runoff general permit,and to apply for a state or federal permit or certification for waterway and wetland <br /> Projects or dam projects.This form and any required attachments constitute the permit application.Failure to complete and submit this <br /> application form may result in a fine and/or imprisonment or forfeiture under the provisions of applicable laws including s.283.91,Wis.Stats. <br /> Personal information collected will be used for administrative purposes and may be provided to requesters to the extent required by <br /> Wisconsin's Public Records Laws(ss. 19.31-19.39,Wis.Stats.). <br /> Use this form for(check all that apply): <br /> OWork in public waters(DNR -ch.30,Wis. Stats.) ❑ Storm water NOI -New land disturbing construction activity <br /> ❑Work in waters of the U.S(Corps of Engineers) ❑ Storm water NO1 -Renewal FIN# <br /> Permit for Wetland Fill(DNR or Corps of Engineers) ❑ Dam projects(DNR or Corps of Engineers) <br /> Read all instructions provided before completing. If additional space is needed,attach additional pages. <br /> ,Ap/plicant N1m Ind.,Org.or Entity) Authorized Representative TiU <br /> 1�f�� ( ✓fin bc,ine(` <br /> Mailing Address City State ZIP Code <br /> ! E. ✓l P VV`1 e b ' MN SSyi <br /> Email Address Phone Number(Incl.area code) IFAX Number(incl.area code) <br /> k-P bass �orc{, Com (oA 2`40-YFE vNE <br /> Name(Ind.,Org,or En ity) Contact PersonLcode) <br /> ( Sine <br /> Mailing Address CityLNumber(incl. <br /> ode <br /> Email Address Phone Numbea code) <br /> Consultant or Plan PreparerContractor ❑Agent ❑Other If Other,specify: <br /> Name Ind.,Org.or Entity) C ct Person Title <br /> arduA1 LLC- <br /> Mailing <br /> LCMailing Address Cay State ZIP Code <br /> -75-(,g'7 coc Wf(00Fr T 93 <br /> Email Address Phone Number(ind.area code) FAX Number(incl.area code) <br /> rZig-JI - 01st <br /> Section 4, act or Site <br /> Project Name Count <br /> 1 ri (� ^�� `�. Y j� ❑ C/ity Town ❑ Village <br /> /C' -(- '/ J <br /> Location Address/Description <br /> Section 5: ONonCreate a map depicting the protect location or the perimeter R the construction site(land disturbance)and relationship to nearby water <br /> resources using the Surface Water Data Viewer http://dnr.wi.gov/top!cJsurfacewater/swdv/or a 7.5-minute series topographic map. <br /> 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 Township F;-Ze If this site isnot wholly contained on the <br /> /v N quarters/(�uartersection,more description: <br /> /. <br /> Lo1fs 3 + q &I-CIL 11) `VAS,"I �.atkelk"C D,alSIL� o' VckaW L'4&'i SAI <br /> to 4-SDkli%a lu(04; rn 6,w1'1)1ned Lot- S/ S-evfrcvl 19 -r'-0i.1AfAt;P ND <br /> )io,qA „F /L-tnge I& V-jefl RI,14eP G',. 1J tv1: <br />