1998-07-17 Water Resource Project Notification/App
LOCAL-STAJE..FEDERAL WATER RESOURCE PROJECT NOTIFICATION/APPLICATION 'FORM
Use this form to notify/apply the MiMesota Deportment of Natural Resources, the Army Corps of Engineers, and your Local Government Unit of a
proposed water/wetland project or work which may faU within their jurisdiction. These agenties should advise you of their jurisdiction or permit
requirements within 45 days. Some LGUs may require submission of their ou-n application forms. This form is provided as a convenience and its usc is
optional. You may, if you wish, apply for permits or authori2:ations using standard agency forms. Fill out this form completely and mail a copy, with plans,
maps, etc. to each of the agencies listed on the reverse of the form. Keep a copy for your records. YOU MUST OBTAIN ALL REQUIRED
AUTHORIZATIONS BEFORE BEGINNING WORK.:
AGENCY USE ONLY: LGU NUMBER: MDNR NUMBER: CORPS NUMBER:
I. Applicant's Name (First, Last, M.I.) / Authorized Agent, if any I Area Code, Telephone
PlIot Land Development Company AttD: Mr. Don Jensen / Westwood Prof~ssional Services, Inc. Attn: l\'lr. Kenneth Po..velll (612) 937-5150
Address (Street, RFD, Box Number, City, State, Zip Code)
13736 NE JohnsDn Street, Ham Lake:, MN 55304 1 7599 Anllgrum Drive, Eden Prairie, MN 55344
II. LOCATION OF PROPOSED PROJECT (ATTACH DRA 'WING SHOWING HOW TO GET TO SITE)
County Quarter Section(s) Seetion(s) No TO'rVnship (s) Range (s) No.
Wright SW 1/4 SeetioD 35 rUIN R24W
Fire No., Box No., 01" Project NDme of Water body Affected and Number. (if known):
Unu:J.med wetlands
LENGTH OF SHORE AFFECTED (in feet):
Lot, Block, Subdivision
III. ESTIMATED PROJECT COST: $
N/A
IV. VOLUME OF FiLL OR EXCA VA TION (cubic yds.):
AREA FILLED OREXCAYATED IS 24,170 sf offill and 3,703 sfofexcavation
V: TYPE OF WORK AND AREA (Check all that apply):
ACCESS PATH BRIDGE CULVER.T DAM
DOCK RIPRAP SAND BLANI<E1' X .FILL
(NOTE: You may substitute dimensions)
CONSTRUCT
REMOVE
DRAIN
REPAIR
X BXCAVATE
D LAKE D SHORELINE 0 WATERWAY W WETLAND
ornER (DESCRIBE):
WETLAND TYPES (5) AND ACREAClE (S) PROPOSED TO BE FILLED /DRAINED:
Pro oS9d Fill & Excavation (sf) Basin Size on ro El S
1.840 6B,673
2,536 & 2,750 19,959
841 . 9,859
7,295 7,295
11,658 & 953 15,545
Attoch drawings and plans. Include a description of any proposed compensatory mitigation
Describe the work below; how it would be done, what equipment would be used:
See attached llarrative
VI. PROJECT PURPOSE (why is this project ncedcd--what benefits ..viII it provide?):
See attached nnrrative
VIr. AL TERNA TIYES (desclib~ any other sites or methods that could be used to achieve the purpose of your projeCt while avoiding or minimizing
wetland/water impacts: Attach lldditional sheets, if needed).
See attached narrative
VIII. DATES: Proposed start of activity; Summor 1998
(identify any completed worl, on drawing).
IX. ADJOINING PROPERTY OWNERS (Attach list if more than two).
Name Address
N/A
Wetland
p9
3
2
1
1
1
Important; Identify any disposal and borrow areaS.
Proposed completion:
Depends 011 Marltct Conditions
City
State
Zip
1.
2
X. PERMITS have been teceived (enter an R), already applied for (enter an A), or will be applied for (enter a W) from:
DNR A ARNIY CORPS COUNTY
A TO'WN/CITY -X- WATERSHED DISTRICT -W MN POLLUTION CONTROL AOENCY
I-Ias an archaeolosieal survey oftlle project site been done? No If so, by whom:
I hereby notify the recipients of this form of tho project proposed herein SlId request that I be advised of any pcnnits or other dej:erminations concerning this
project that I must obtain. I Wlderstand that proceeding with work before all required authorizations are obtained may subject me to Federal, State, and/or
local administr e, civil and/ r . . at penalties.
DATE: 7/7/q
<<<<<PLEASE CAREFlTLL Y READ AND COMPLETE BACK OF FORM>>>>>
INSTRUCTIONS-PLEASE READ CAR-EFULL Y
A copy of this form, with copies of all plans, drawings, etc., should be sent to each agency indicated below.
Please check the appropriate spaces below to show everywhere you are sending this form. Remember to keep a copy for your records.
~ LOCAL GOVERNMENT UNIT (LGU): City, county, or watershed mEUlagement orgEUlization.
Specify the LGU to which you are sending the form: City of Albertville
X The local SOIL AND WATER CONSERVATION DISTRICT (SWCD) for the project.
Specify the county SWCD: Wrllil'l1t County 5011and Water Conservation District
WATERSHED DISTRICT (if one exists for the project area).
Spccify the Watershcd District:
MINNESOTA DEPARTMENT OF NATURAL RESOURCES Regional Office.
X U.S. ARMY CORPS OF ENGINEERS (ACOE). Send the ACOE copy to:
Department 01' the Army, Corps ot' Englneers, Sf. Paul District,
ATTN.: CO-R, 190 Sth 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 iac:luding drainage, dredging, tilling, leveling or other manipulations, intluding maintenance, may
affect a land USer'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-I026 prior to Initlating activity. '
IMPORTANT: Some of the above offices may allow this form to be used as a permit app1itation 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, EUldlor 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 pennits to authorize the activities described herein. I certify that 1 am familiar with thc information contained in
this application, and that to the best of my knowledge and belief such information is true, completlll, and accurate. I further certify that I possess the
author' 'Y to unde <13 the proposed activities or r am acting as the duly authorized agent of the applicant.
1/?P
Signature of Agent
Date
N01E: The application must be signed by the person who desires to undert.ake the proposed activity (applicant) or it may be signed by a duly authorized
agent if the infom1lltion requested below is provided.
Agent's Name:
Ken Powell
Agent's Title:
Environmental Scientist
Agent's Address:
Westwood Professional Services, Inc., 7599 An:lZrllm Drive
Edell Prairie, Minnesota 55344
Agent's Telephone:
(612) 937-51,50
Agent's Ernail:
POwelll{@westwo~dps.com
18 U.S.C. Section 1001 provides that: Whocvcr, in any m:mncr within thejurisdictioll of allY department or agency of The United States knowingly and
willfully falsifies, conceals, or covers up by any triclc, scheme, or device a material fact Dr 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 fmed
not more than $10,000 Or imprisoned not more than five years, or both.
SEE ATTACfIMENT ABOUT l\-IDNR PERMIT FEES