Laserfiche WebLink
State of Wisconsin Water Resources A <br /> Departmentco Natural Resources project Permits <br /> dnr.wi.gov Form 3500-0 31R 08109) Page 1 <br /> LIAR $3 2011 <br /> Use this form for(check all that apply): Notice: This form'yI,55,� s to a ��Iyy for coverage under the <br /> state construction sltE�9RERJ61@*a1 permit, <br /> ®Work in public waters(DNR—ch. 30, Wis. Stats.) and to apply for a state or federal permit or certification for <br /> ❑Work in waters of the U.S (Corps of Engineers) waterway and wetland projects or dam projects. This <br /> application form is authorized by chs 30 and 31,Wis. Stats, <br /> ❑ Permit for Wetland Fill (DNR or Corps of Engineers) for Alterations to Public Waterways, ch.281,Wis. Stats,for <br /> Wetland Fill and s.283.33,Wis. Stats.,for Storm Water <br /> ❑ Storm water NOI—New land disturbing construction activity Discharges. Personally identifiable information on this form <br /> ❑ Storm water NOI—Renewal FIN# may be used for other program purposes and may be made <br /> ❑ Dam projects (DNR or Corps of Engineers) available to requestors under Wisconsin's Public Records <br /> laws and be posted on the Department website. This form <br /> Read all instructions provided before completing. If additional and any required attachments constitute the permit <br /> space is needed, attach additional pages. application. Failure to complete and submit this application <br /> =may result in a fine and/or imprisonment or forfeiture <br /> under the=in <br /> of applicable laws. <br /> !Section 1:Applicant Information <br /> Applicant Name(Indiv.t Org. oorr,Entity) Auth ri R�$entawe� Tit � D a �G <br /> •( f}j2tJ Iv N N !i <br /> ailing Addre s Ci <br /> 33 LEA ,b l_ao A� eT ,1 ive"e-Via.,r State Ppto sto S <br /> mail address Telephone Number(include area code) Fax Number(include area code) <br /> ./VACO 4a(o3DUZi"Jo- .eo1171 63o- Sal- yolsb - <br /> Section 2: Landowner Information if different than Applicant) <br /> Na a("Orggark¢ation or Entity) Co tact�P,e—rsor� Title <br /> I<i4K-EN NX1-So Agzt M &-So L PC t] D a W tv Cri <br /> Mailing Address City S t Postal Code <br /> 1133 LiA RWk, Cr M kPEa2V ISE /�©s&,r <br /> E-mail addressTelephone Number(include area code) Fax Number(include area code) <br /> KNASO gR(o,3C1<)OcciccJ e0m J�30-sal- -70&b <br /> Se •on 3: Other Contact Information Jcheck one): <br /> Consultant or Plan Preparer ❑Contractor ❑Agent ❑Other If Other, specify: <br /> Name(Or anization r Entity) ^ Con ct P rson Title 7 <br /> tJ ��QQ�. II Ave-rJnwJ/1s5. ..„IIef�iJ ��v�3vV� II(iK-5tJ <br /> M iliH. <br /> ztgddMnc1� AS. City Mtlnr�+ SMn PoS_rT <br /> li <br /> E-mail aap�dress Telephone Number Include area code) Fax Number(include area code) <br /> L'urtr'd ® wtat�.ra+� (i12— $I>o - 31 <br /> Section 4: llro•ect or Site Location <br /> Siteoml(ifany) not — r Sh C unty L Municipality 1 t <br /> wst <br /> kk T eh, rVv.-�L seo CC <br /> Locatio Address/De_%cnption <br /> .�(06ck k vo L L RD. ❑ City ❑Village Township <br /> %gection 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. oq v/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 Surve System) Method <br /> Quarter-Quarter Quarter Section Township Range Direction If this site is not wholly oDnteine& <br /> ❑ NW [SNE ❑ NW ❑ NEbn the quarter-g Tterseriot'f <br /> ElSW ElSE ElSW ElSE N5� U N ❑ E 1 [RW E moredescnptlon- <br /> 17 0 <br /> Go V dor a- <br />