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Water Resources Application for <br /> Project Permits <br /> Form 3500053 (R 9112) <br /> • .• • - .•• • •• - • -• - <br /> Name(descripton if unnamed)of closest waterbodies Type Special Status <br /> P ( I ow 0 Lake 0 Stream 0 ORWIERW 0 303(d)listed <br /> Yes ,N�o,jWetlands: <br /> ElL� 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(attached report) <br /> ❑Wetland Locator ToolElSoils E] Other: <br /> http://dnr.wi.gov/topicNJetlands/localing.html (NRCS maps) <br /> Applicant/Project Name: County <br /> Latitude and Longitude Method(if available) <br /> Degrees Minutes Seconds Method ofDetennlning <br /> ❑ GPS <br /> Latitude ❑ DNR's Surface Water Data Viewer <br /> ❑ Other: <br /> Longitude <br /> — _P�ct Information(attach additional sheets as necessarv) <br /> Anticipated Project Start Date(mm/ddtyyyy) Anticipated Project End Date(mm/dd/yyyy <br /> Duration: �Orva l A64 ^A64WN4 ZS ZO13 <br /> Date of PhotoggFaphs(mm dlyyyy) <br /> Photos: Provide photographs of the"before"condition. <br /> Narrative of the Project: <br /> Provide a one to two paragraph description of the proposed project,including land and water alterations and intended use(s)of the <br /> project. <br /> The following attachments,such as the construction Erosion and Sediment Control(form 3500-052A)and the Post-Construction Storm <br /> Water Management(form 3500-0526)for a storm water construction permit application,constitute this permit application: (include all <br /> that apply) <br /> Attachment name(s): <br /> ❑ I have obtained a copy of the construction site storm water runoff general permit from the <br /> department's internet site: http://dnr.wi.govftopic/Stormwater/construction/forms.html <br /> Section 9: Certification and Permission <br /> Certification: I hereby certify that I am the owner or authorized representative of the owner of the property which is the subject <br /> of this Permit Application. I certify that the information contained in this form and attachments is true and accurate. I certify that <br /> the project will be in compliance with all permit conditions. I understand that failure to comply with any or ail of the provisions of <br /> the permit may result in permit revocation 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 this <br /> notice and application, and to determine compliance with any resulting permit coverage. <br /> Na e o O ner/Auth 'zed Representative(please print) Title P ne N mbar <br /> -� ��� �°e z yo-sir <br /> SignatupVbf Aolplicent Date Sign <br />