6.8. - 6.10. SR 08-17-1998 - Laserfiche WebLink

Home Browse Search

INSTRUCTIONS-PLEASE READ CAREFULLy A copy of this form, with copies of all plans, drawings, etc., should be sent to each agency indicated below. Plea~ check the appropriate spaces below to show everywhere you are sending this form. Remember to keep a copy for your records· X LOCAL GOVERNMENT UNIT (LGIY): City, county, or watershed management organization. Specify the LGU to which you are sending the form: City_ of Elk Rtvcr X The local SOIL AND WATER CONSERVATION DISTRICT (SWCD) for the project. Specify the county SWCD:. Sherburne Soil and Water Conservation District WATERSHED DISTRICT (if one exists for the project area). Specify the Watershed District: X MINNESOTA DEPARTMENT OF NATURAL RESOURCES Regional Office. X U.S. ARMY CORPS OF ENGINEERS (ACOE). Send the ACOE copy to: Department of the Army, Corps of Engineers, St. Paul District, ATTN.: CO-R, 190 5th Street East, St, Paul, MN 55101-1479 Note: The above agencies may provide a copy of your completed form to the Minnesota Pollution Control Agency (MPCA). MPCA water quality rules may apply to your proposal. ATTENTION! FROM USDA: Any activity including drainage, dredging, filling, leveling or other manipulations, including maintenance, may affect a landuser's eligibility for USDA benefits under the 1985 Food Security Act as amended. Check with your local USDA office to request and complete Form AD-1026 prior to initiating activity. IMPORTANT: Some of the above offices may allow this form to be used as a permit application form. The Corps of Engineers will accept this form as an application form. If you wish this form to constitute an application to the Corps of Engineers for any necessary permits for your project under Section 10 of the Rivers and Harbors Act of 1899, and/or under Section 404 of the Clean Water Act, please carefully read the following information and sign where indicated below. Application is hereby made for a permit or permits to authorize the activities described herein. I certify that I am familiar with the information contained in this application, and that to the best of my knowledge and belief such information is true, complete, and accurate. I further certify that I possess the ~ature of Applicant Date S~gna~tur~ of Agent Date NOTE: The application must be signed by the person who desires to undertake the proposed activity (applicant) or it may be signed by a duly authorized agent if the information requested below is provided. Agent's Name: Rob Bo~;a Agent's Title: Senior Environmental Scientis~ Agent's Address: Westwood Professional Services. Inc., 7599 Anagram Drive Eden Prairie. Minnesota 55344 Agent's Telephone: _. (612) 93%5150 Agent's Email: boutar~westwoodps.com 18 U.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction of any department or agency of The United States knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact or makes any false, fictitious, or fraudulent statements or representations or makes or uses any false writing or document knowing same to contain any false, fictitious, or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years, or both. SEE ATTACHMENT ABOUT MDNR PERMIT FEES