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State of Wisconsin U ��(,`�yyater Resources Application for Project Permits <br /> Department of Natural Resources <br /> dnrvi.gov /1Form 3500-053(R 08I09) Page 1 <br /> � <br /> Use this form for(check all that apply): IF <br /> SQ9?1WMce: This forth is used to apply for coverage under the <br /> (J state construction site storm water runoff general permit, <br /> El Work in public waters(DNR—ch. 30,Wis.Stats.) ®�9 apply for a state or federal permit or certification for <br /> F1 Work in waters of the U.S(Corps of Engineers) we y 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,We.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 form <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 forfeiture <br /> under the provisions of applicable laws <br /> Section 1:Applicant Information <br /> plicant Name(Indiv., Org. or Entity) Authorized Representative Tile <br /> CV/?e .owl7er <br /> Mailing Addre sCi Ste Postal Code <br /> z r n bs 15 7 8 3 <br /> E-mail address Telephone Number(include area code) Fax Number(include area code) <br /> 7/ -- 6 - 9 <br /> Section 2: Landowner Information if different than Applicant) <br /> Name(Organization or Entity) Contact Person Title <br /> -5 er h-i e, <br /> Mailing Address City State Postal Code <br /> I <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) County Municipality <br /> 83 r Ulebsre-- rne- <br /> Location Address/Description 'I�' L ` . �. <br /> u Rk.65 VEL. :5q,993 ❑City ❑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.wi.ciov/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 Method <br /> Quarter-Quarter Quarter Section Township Ran a Direction If this site is not wholly contained <br /> ❑NW ❑NE ❑ NW ❑ NEN 11 <br /> El ogthedgqua� rtscrier--quarter section, n <br /> �SW El SE El SW ,�SE ❑W n u, >°i ray 1-6fS '34 L1 IC <br />