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State of''disconsin U.S. Army Corps of Engineers-St.Paul District STATE/FEDERAL APPLICATION Deparnent of Natural Resources Regulatory Functions FOR WATER REGULATORY (Return to appropriate 190 Fifth Strcet East PERMITS AND APPROVALS DNR District/Area Office) St. Paul,Minnesota 55101-I638 Form 3500-53 Rev.9-95 PLEASE COMPLETE BOTH PAGES 1 &2 OF THIS APPLICATION. PRINT OR TYPE.Use of this form is required by the Department for any application riled pursuant to Chapter 30.Wis.Stats. The Department will not consider your application unless you complete and submit this application form. Personally identifiable information on this form is not intended to be used for any other purpose. 1. Applicant(Individual or corporate name) 2. Agent/Contractor(firm name) h Voyager Land Company, Ltd. same Address Address 28851 Kilkare Road City,State,Zip Code Fire Number City,State,Zip Code Danbury WI 54830 Telephone No.(Include area code) traParcel Number Telephone No.(Include area code) 715/259-3910 ' M 3 YA 028 4118 3. If applicant is not owner of the property where the proposed activity will be conducted,provide name and address of owner and include letter of authorization from owner. Owner must be the applicant or coapplicant for structure,diversion and channel change activities. A purchaser under a land contract is not considered a riparian owner until property transfer has occurred. Owners Name Address City,State,Zip Code 4. Is the applicant a business? El Yes ❑ No 5. Project Location If YES,is the permit or approval you are applying for Address necessary for you to conduct this business in the State Village/Cityr wn Scott Township of Wisconsin? • ❑ Yes N No If YES,please explain why(attach additional sheets if Waterway Birch Island Lake — necessary): County Burnett Govt.Lot_ OR NW 1/4 NW 1/4,of sectionl 8 Township 40 North,Range14W (East)(West) 6. Adjoining Riparian(Neighboring Waterfront Property Owner)Information Name of Ri Arian,#1_ :. . Address City,State,Zip Code -'r. 4 1 i.1k-are Road Danbury WI 54830 ame of Riparian tt2 Address City,State,Zip Code Pearl Br-id e 28730 Bride Rd Danbury WI 54830 7. Project Information(Attach additional sheets if necessary) (a)Describe proposed activity(include how this project will be constructed) see attachments Baot Dock - plactic- galvanized steel - stainless steel - cement anchors (b)Purpose,need and intended use of project To expand our existing marina and To' fullfill the demand for dock spaces on Birch Island Lake for P.O.A. members (c)I have applied for or received permits from the following agencies: (Check 4) ❑ Municipal ❑ County [ Wis.DNR ❑ Corps of Engineers (d)Date activity will begin if permit is issued .spring 1998.be completed: same (e)Is any portion of the requested project now complete? If yes,identify the completed portion on the enclosed drawings ❑ Yes ® No and indicate here the date activity was completed: I hereby certify that the information contained herein is true and accurate. I also certify that[am entitled to apply for a permit,or that I am the duly authorized representative or agent of an applicant who is entitled to apply for a permit. Any inaccurate information submitted may result in permit revocation,the imposition of a forfeitures)and requirement of restoration. Signature of Applic t(s)or Duly Au orized Agent - Date ,Signed —�— � - LEAVEC U C ONLY orps of Engineers Process No. Wisconsin DNR File No. lication Was Complete Received By Date Received Date App