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<br /> State of Wisconsin RECEIVED Water Resources Application for Project Permits
<br /> Department of Natural Resources Form 3500-053(R 08/09) Page 1
<br /> dnr.wi.gov AUG 18 eon a�o -a o�7-
<br /> -y 36 s-/-5---.5 77-assaL)D
<br /> Use this form for(check all that apply): PERI- 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 /> ❑ Permit for Wetland Fill (DNR or Corps of Engineers) for Alterations to Public Waterways,ch.281,Wis. Stats,for
<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
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<br /> SeCYIOn ..A llcarifinformaHOri
<br /> Ap Iicant Name Indiv., Org. or Entity) Authorized Representative Title
<br /> t� ,! Cdr0sS
<br /> Mailing Address o ` 1 Cty 9 tate Postal Cod
<br /> ® 110-35 17an1 r� k.-cl" &pke— JK11 a SS 1'0
<br /> E-mai address Telephone Number(include area code) Fax Number(include area code)
<br /> g�}} E,.ri.'.
<br /> AI
<br /> , �: a
<br /> Secf Or11 , andOWrier'tnfor`rtiatlonF Ift�lil2rent.l�lan.'H hC2flt Y:. . ,^�?„-;»,''...,,:«�y`?F5 nx .,via ,i
<br /> Nine(Organizati or Entity) Contact Person Title
<br /> 9.V_ j ✓'o 455
<br /> Mailing Address City State Postal Code
<br /> E-mail address Telephone Number(include area code) Fax Number(include area code)
<br /> 'Ie . syn s .A a,1 s t 3;.,",215»>.+.*z, x 's' x i .. .s ,.. s .'U A. -s .z Q. t e •r y.
<br /> SecIont3 ,Oiher,,t>ontact:lnfo[matlon: cieckone �fx r3 '< ,,, ,..,n, �s T {,
<br /> ❑ Consultant or Plan Preparer El Contractor ❑Agent XOther
<br /> Ifther, ecify:
<br /> nrw u.irvlt✓ saH'K. q5 c.lornit,
<br /> Name(Organiz on or Entity) Contact Person Title
<br /> r � 5> k ^ e . v. ivy-✓
<br /> Mailing s 7 p ii gtate Postal Co e
<br /> 035 YN �� tPL ur%t PJ 1 S51"
<br /> E- II address Tele hone Number(i clude a a code) Fax Number(include area code)
<br /> 11L-4532- 1432
<br /> "^,$eC Ot14�: CO CCC',O�SItB}LUC3YiOrlsk+• .. "Yr.�~ .'
<br /> pA,� `�t}£., � �.... r,` fse#. �.°,fJ1 �? r::s
<br /> Site Name (if any) >;�ounty ,i �v1 uniciRality
<br /> t�jurne�lC �.1va�w. �v r^.st-, z
<br /> Locatio Addr ss/Description
<br /> W s`� (3 ❑ City ❑Village KTownship
<br /> ".S`eC lOt s.].y LSOC`att�NlnfOfRl2YlOrl�.z,> x. t•:-'uz".Stf#J}.d�"7
<br /> NO - " , i0. R w. ,''`.
<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.gov/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=QUartdri� l;',4'•Quartdr= S otion �5>,tTdwnshi ;i Ran e'D'Ditectiort If this site is not wholly contained
<br /> ❑ NW ❑ NE ❑ NW ❑ NE L� El on the quarter-quarter section,
<br /> 36 / 0 N more description:
<br /> 0 SW "Fri SE ElSW MSE W
<br />
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