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State of Wisconsin Water Resources Application for Project Permits <br /> Department of Natural Resources <br /> dnr.vA.gov Form 3500-053(R 08109) Page 1 <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 chs 30 and 31,Wis.Stats, <br /> for Alterations to Public Waterways,ch.281,Wis.Stats,for <br /> E] Permit for Wetland Fill(DNR or Corps of Engineers) <br /> 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 /> Applicant Name(Indio., Org.or Entity) Authorized Representative Title <br /> I r1 G)' <br /> 5 i f d 114(5 G Ci�^ l �n i� to Postal C <br /> �r l '�ftl nl 553 <br /> E-malil address Telepphone Nu bar(incl area code) ax Number(include area code) <br /> :U E16 t4 3@ e.u (v f 2 . 3 lo- F� <br /> Section 2: Landowner Information if different thanApplicant) _ <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(Organizationyr n 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) un MuryciptyOrr <br /> �s�o <br /> Location Address/Description K <br /> ❑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 htto:Hdnr.wi.ciov/ora/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 System)Method <br /> Quarter-Quarter Quarter Section Township Range Direction If this site is not wholly contained <br /> ❑NW ❑ NE ❑NW ❑NE on the quarter-quarter section, <br /> El SW ❑SE ❑SW C]SE / 3g N I �j W more description: <br />