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Water Resources Application for Project Permits <br /> Fom 3500-053 R 08/09 Page 2 <br /> Appliwnt/Project Name: County: <br /> Latitude and Longitude Method if available <br /> De rees Minutes Seconds Method of Determining <br /> Latitude ❑GPS <br /> ❑DNR's Surface Water Data Viewer <br /> Longitude ❑Other(specify): <br /> Section 6:Waterways and Wetlands see Instructions about potential additional apRlication requirements) <br /> Name(description if unnamed)of closest waterbodies Type Special status <br /> IJ �jo ha�� j�rLake ❑Stream ❑ ORW/ERW ❑303(d)listed <br /> Yes No Wetlands: �S <br /> ❑ K 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(attach report) <br /> ❑Wetland Locator Tool ❑Soils(NRCS maps) ❑Other(specify) <br /> httD://dnr.wi.gov/wetlands/locating.htm <br /> Section 7: Project Information Attach additional sheets as necessary) <br /> Duration: Anticipated Project Start Date(month/day/year) Projected Project End Date(month/year) <br /> Photos: Provide photographs of the"before'condition. Date of Photographs: <br /> Narrative of the Project: <br /> Provide a one to two paragraph description of the proposed project, including land and water alterations and intended <br /> use(s) of the project. <br /> Section 8:Attachments and Permit Access(Include appropriate attachments for each proposed activity.) <br /> The following attachments,together with this form,constitute this permit application: (include all that apply) <br /> Attachment Name(s) <br /> LJ I have obtained a copy of the construction site storm water runoff general permit from the department's Internet site. <br /> http://dnr.wi.aov/runoff/Ddf/stormwater/permits/construction/construction permit 5067831-3.odi <br /> Section 9: Certification&Permission <br /> Certification: I hereby certify that I am the owner or authorized representative of the owner of the property which is the <br /> subject of this Permit Application. I certify that the information contained in this form and attachments is true and <br /> accurate. I understand that failure to comply with any or all of the provisions of the permit may result in permit revocation <br /> 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 <br /> this notice and application,and to determine compliance with any resulting permit coverage. <br /> Name of Owner/Author' ed Representative(Print or Type) Title Telephone Number <br /> LOP-VAa -1. � e ;roCK owr, e r lis- ,/I7. p8b' <br /> Signature j Date Signed <br /> � - <br /> LEAVE BLANK-AGENCY USE ONLY <br /> Date Received Fee Received Construction Site ID# Docket# 6 V - Corps# <br /> S -S - 2o II S SO .oa 2ott-�-O5qb9 <br /> InitiqlI screening: -- ��� <br /> ❑'Completeness L� <br /> istoric checked 'Rare species(NHI)checked 15'Wetlands checked <br />