2010/04/26 - OTHER - (NA) - Note

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disconsin Attachment-Replacement of an Existing Seawall with Riprap .ment of Natural Resources General Permit Application Packet(R1-09) ,vw.dnrwi.gov page 2 of 4 Section 3: Submittal Requirements Yes I have submitted a$50 PERMIT APPLICATION FEE, in the form of a check,payable to"Wisconsin DNR." I have prepared and submitted DETAILED PLANS AND/OR DRAWINGS,which clearly illustrate the project has been designed and will be constructed in compliance with all of the General Permit Eligibility Standards. I have submitted LEGIBILE SITE MAPS,which clearly Illustrate the perimeter of the construction site and relationship to nearby water resources(e.g.lakes,rivers,streams,wetlands)and major landmarks and roads. " have submitted CLEAR PHOTOGRAPHS,which illustrate the entire project site in pre-construction f>a :ondition and the relationship to nearby water resources. have submitted a COMPLETED GENERAL PERMIT ATTACHMENT and provided 3 COPIES of the entire rpplicatioq package. lection 4: Certification Yes hereby certify that I am the owner or authorized representative of the owner of the property which is the ubject of this permit application. certify that the project has been designed and will be constructed in compliance with all of the General ermit Eligibility Standards. certify that the information contained in this application submittal is true and accurate and understand wt failure to comply with any or all of the provisions of the issued permit may result in permit revocation,a ne and/or imprisonment or forfeiture under the provisions of applicable laws. .mderstand that 1 am responsible for obtaining all necessary local(e.g.city,town,village or county) id U.S.Army Corps of Engineer permits or approval in addition to this state General Permit and prior to )mmencing any work at the project site. action 5: Permission Yes hereby give the Department permission to enter and inspect the property at reasonable times,to valuate this notice and application,and to determine compliance with any resulting permit coverage. fiction 6: Landowner or Authorized Representative Signature ?ase sign below. By signing you are certifying that all of the requested items contained in this permit application :achment has been fulfilled and the appropriate documentation is attached. me of Owner/Authorized Representative(please print) Title Telephone Number V i T' n, m /S 6— 4/.Z ature Date Signed -4 /0