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r (vi Ywe 4 Co. —20©n rn eq <br /> • J 6P. No- a01a - 7 - oIy16 <br /> State of Wisconsin Water Resources Application for Project Permits <br /> Department of Natural Resources Form 3500-053(R 08/09) Page 1 <br /> drrwi.gov <br /> Use this form for(check all that apply): Notice: This form is used to apply for coverage under the <br /> state construction site storm water runoff general permit, <br /> ❑Work in public waters(DNR—ch. 30,Wis.Stats.) and to apply for a state or federal permit or certification for <br /> ❑Work in waters of the U.S(Corps of Engineers) waterway and wetland projects or dam projects. This <br /> application form is authorized by ohs 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) Weiland Fill and s.283.33,Was.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 /> form may result in a fine and/or imprisonment or forlsiture <br /> under the provisions of applicable laws. <br /> Section 1:Applicant Information <br /> A pII7t Name(Indio.,Org.or Entity) A thorized Representative Title <br /> Gp s T. U — OWN£ <br /> M 'ing Address City State Postal Code <br /> � .3 V16 <br /> '! �U L U TI-1 , L£woo /V Syla 9 - <br /> E-mail address Telephone Number(include area code) Fax Number(include area code) <br /> - he nfs1!3 s' , wlrvt - �Y .7 , C <br /> Section 2: Landowner Information if d'dferent than Applicant) <br /> Name(Organization or Entity) Contact Person Title <br /> Mailing Address City State Po de <br /> E-mail address Telephone Number(include area code) Fax Number(include'area e) <br /> Section 3:Other Contact Information check one): <br /> ❑Consultant or Pian Preparer IV Contractor ❑Agent ❑Other If Other,specify: <br /> Na a(Organization or Entity) Contact Person Title <br /> Gt>A r Z 9CH RTZ Q £.— <br /> Mailing Address CRY State Postal <br /> Cl nn S's <br /> E-mail address Telephone Number(ncude area code) Fax Number Qnclude area code) <br /> Section 4:Project or Site Location <br /> Site Name(if any) Courtly Municipality <br /> 174 A) <br /> Location Address/Description <br /> E£N ❑City El Village Township <br /> Section S: Location Information <br /> Create a map depicting the perimeter of the construction site(land disturbs )and relationship to nearby water <br /> Vi <br /> resources using the Surface Water Data ewer htt0://dnr.wi.gov/org/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 I0Aethod <br /> ip <br /> uarter Quarter Section TownshipDirection ff this site is not wholry contained <br /> ❑NE ❑NW ❑NE TON �,,- ❑W on the quarter quarter section, <br /> / J more descriptiom <br /> ❑SW ❑SE SW ❑SE <br /> L5-160 ' c>F A 00' caf' 6o or /, OT-5, F,,fAd 61- 0/2 `il,296-02Q80 <br />