Laserfiche WebLink
� w . gyp- No -�dl/- '7 <br /> State of NAseonsin Zo-vu�^e� — `qL'l RFS. Water Resources Application for Project Permits <br /> Department of Natural Resources G �r�n Form 3500-053(R 08109) Page 1 <br /> dnrwi.gov ��,�\ G CQ a�O3(�-a-q(o-/7-&-';-/S 577-0--- 2 <br /> Use this form for(check all that apply): 1& jJ Notice: This form is used to apply for coverage under the <br /> A� state construction site stone water runoff general permit, <br /> ❑Work in public waters(DNR—ch. 30,Wis.Stats.)Rj and to apply for a state or federal permit or certification for <br /> ❑Work in waters of the U.S(Corps of Engineers) �iQ waterway and wetland projects or dam projects. This <br /> application forth is authorized by chs 30 and 31,Wis.Stats, <br /> for Alterations to Public Waterways,ch.281,Wis.Stats,for <br /> ❑ Permit for Wetland Fill (DNR or Corps of Engineers) Wetland Fill and s.283.33,Wis.Stats.,for Storm Water <br /> ❑ Storm water NOI—New land disturbing construction activity Discharges. Personally identifiable information on this form <br /> ❑Storm water NOI—Renewal FIN# may be used for other program purposes and may be made <br /> ❑ Dam projects(DNR or Corps of Engineers) available to requestors under Wisconsin's Public Records <br /> laws and be posted on the Department website. This forth <br /> Read all instructions provided before completing. If additional and any required attachments constitute the permit <br /> space is needed,attach additional pages. application.Failure to complete and submit this application <br /> forth may result in a fine and/or imprisonment or forfeiture <br /> under the provisions of applicable laws, <br /> Section 1:Applicant Information <br /> pplicant Na a Indiv., Org.or Entity) Authorized Representative Title <br /> Cnde) rf-'brocK n9- v- <br /> M [ling Address City State Postal Code <br /> M o i o4-A Si o S ce of a.- Lit z o r3, o <br /> E-mail address Telephone Number(include area code) Fax Number(include area trade) <br /> 715= 1 -7 - ova <br /> Section 2: Landowner Information if different than Applicant) <br /> Name(Organization or Entity) Contact Person Title <br /> Mailing Address City State Postal Code <br /> E-mail address Telephone Number(include area code) Fax Number(include area code) <br /> Section 3:Other Contact Information check one): <br /> ❑Consultant or Plan Preparer ❑Contractor ❑Agent ❑Other If Other,specify: <br /> Name(Organization or Entity) Contact Person Title <br /> Mailing Address City State Postal Code <br /> E-mail address Telephone Number(include area code) Fax Number(include area code) <br /> Section 4: Project or Site Location <br /> Site Name(if any) C my Municipality <br /> (,l.t^0-e-`4--�- <br /> Location Address/Descripbon <br /> ,Y,;9R C v-Coro-V) b U n r'o s1 ❑City El Village Township <br /> Section 5: Location Information <br /> Create a map depicting the perimeter of the construction site(land disturbance)and relationship to nearby water <br /> resources using the Surface Water Data Viewer http://dnr.W.00vloro/water/data viewer.htm or a 7.5-minute series <br /> topographic map.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 stem Method <br /> Quarter-Quarter Quarter Section Townshi Range Direction If this site is not wholly contained <br /> El NW [INE El NW El on the quarter-quarter section, <br /> G10 N S pKW more description: <br /> ❑SW E El I 16SE v <br />