2004-02-02 App for Cert of No Loss or Exemptionf''
Minnesota Wetland Conservation Act
APPLICATION FOR
CERTIFICATE OF NO LOSS OR EXEMPTION*
APPLICANT AND PROJECT LOCATION INFORMATION
M:chae I Po~••ftrc-
Name(s) of Applicant
_116 50 5 7'"' S~. ,y~E
Street Address
_A l be c'fv~ 1 ~t j /U1N 5S3o I
City, State, Zip Code
~G3 yS 7-77Y9
Telephone (Davl (Fven;~ol
LGU: G:~y a_-~Alberfv;lle
Project Location:T ~~ R Z3 S b 1/4~!w 1/4_ 1/4
UTM Coordinates: X: K 7 y; 40 Z 1$
County Name/Number: l~ ~; q~ f
Minor Watershed Name/Number:
Size of entire wetland: l r• r acres
Wetland type: Circular 39 3 ; NWI EM G F
Check one: ~<50% o ~0%-80% or o > 80%
Check one: ^ A 'cultural Land; 1~Non-ae. land
PROPOSED PROJECT DESCRIPTION
Describe the nature and purpose of the proposed project: The- ~7or ~~ or+S o -~ -~ne WC'~land ~o
be ~L':u~~ ~.~ ~o~ -~. a~ye/oprri ~f of ~~-per-s ce~, ~G;4~
DA(k ih ~1b~("FV:IIG /~iN-~12S01~o`
(attac'h additional pages if needed)
Timetable: ro'ect will be ' ono 1 / o I / ~ t (mo/dav/ )and will be com feted b o ~ / o - /Zoo 6
,`` ,_ -.;
~``':~~~~ The wetland activity at the above site qualifies for the following under the Wetland Conservation Act (WCA) (check one):
~ No Loss Determination (attach plans)
1~' Exemption # S h_ ~~• ~ (pef lye Rule Chapter 8420.0122) (Note: Applicant is responsihle for submitting the proof
necessary to show qualiftcation for the exemption claimed.)
Description of Exemption Claimed:
INGA Raps GLta,p•e r 81.120 o I z2 ltJe ~•lg „~ FXew,,P~; oHS ~ Sa bear ~ ~~
A~pro~cJ~ I~v,•~„a.~.,a~-}- ~~t1:w,•~ ~.. ~Ja--~~oro~gl w~.s
o ~ -!•a•,~.~ a w • ft,;.• ~'t^e c'ei~ti rya ~•,N,~ ~~.. ~G
APPLICANT SIGNATURE
The information provided for this determination is truthful and accurate to the best of my knowledge. I ensure that, in draining
or filling the subject wetland under an exemption noted above, appropriate erosion control measures will be taken to prevent
sedimentation of the water, the drain or fill will not block fish passage, and the drain or fill will be conducted in compliance with
all other applicable federal, state and local requirements, including best management practices and water resource protection
requirements established under esota Statutes, Chapter 103H.
(Signature of Applicant) (Date)
Certificate of Exemption/No-L,oss
Page l of 2
Note: Any approval is not ejjecfive until signatures below are complete No work should begin until the 1~-day appeal
window has lapsed, or, in the event ojan appeal, until the appeal has been fnaliyed
*APPROVAL OFTNIS CERTIFICATE ONLY APPLIES TO THE WCA Permits from local, state, and federal agencies may.
be required. Check with the appropriate authorities before commencing work in or near wetlands. The Combined Project
Application form can be used for this purpose.
Within 10 days of the decision, notice of the above decision must be mailed to:
Landowner/Applicant
Members of the Technical Evaluation Panel
Department of Natural Resources Regional Office
DNR Wetlands Coordinator @
Ecological Services Section
500 Lafayette Road, Box 25
St. Paul, MN 55155
Corps of Engineers Project Manager @
Deparnnent of the Army, Corps of Engineers, St. Paul District
ATTN: CO-R, 190 Fifth Street East
St. Paul, MN 55101-1638
Members of the public who have requested to receive notice.
a:exmpcert (Sept, 1999)
rr
~~-
i
Certificate of ExemptionMo-Loss
Page Z of 2