No Date Wetland Conservation Act Certificate of Exemption
WETLAND CONSERVATION ACT
CERTIFICATE OF EXEMPTION OR COMPUANCE OR NO LOSS*
LGD ADDRESS
AND PHONE NUMBER
i~iJ~ l2.oESSl.LF12. Ke..ko L1JS7IllA-c.fiou ::1Jl-' /3763 JcJlI,}sOJJ
(Name, address, and phone of applicant)
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PA 12-1<- Si de -r#; /L/) A ()LJ " f i ov
(Description of projectlName of development)
P~ILT O~>>~'-t'S-C?"c...2-. r: IZ.OP.'-IL.Z.~W FIVI-.JI<.-tDlf
(Location of work: Towilship, Range, Section, Qtr. Section, Lot, Block,Subdivilion, City, County)
(For lCalOnaVannual exemption attach propolCd general location information, i.e. mapa, aerial phOlOI)
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The wetland activity at the above site is exempted from or in compliance with the . Wetland Conservation ActCNCA) for the
following reason: [please Circle (A). (B), (C), (0), OR (E))
This - exemption certification expires
(Dole)
(A)., A Wet1alldDoes NotExi~' I\D
(B)
Exemption.'
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; OR,
(C) Wetland Loss 1-188 Been Avoided; OR
@) Wetland Has Becn~laced As Pee Approved Plan (attached); OR
(E) No Loss Determination (attach plans).
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The information provided for this determination is truthful and accurate to the best of my knowledge.
..it:.
(Applicant Signature)
J<"
"iDated)
(LGU Official Signature)
(Dated)
. THIS CERTIFlCATlON ONLY APPLIES TO THE WCA OF 1991. Permita Crom local. lUte, aDd federal agenciel may be requircid. Check willa 1bc
appropriate authorities beCore commencing work in or near wetlaDda. The Combined Project Notification form can be ulCd for thia PUrpolC.
FOR AU EXEMPTIONS: A landowner drainin, or filling a wetland under an exemption aIlall enaure that; appropriate eroaion coolrol mcalUCCI aro
taken. to prevent. sedimentation . of the water, the drain or fill doca DOt block fish PassaiC, aDd the drain or liIe ia coDducted in compliance ....ith all olhor
appli~a~lefe~l:,lJ!:I'i~te and l.ocal!'Cquireme~ls. including best II'&nagement practice. and waler relOlll'Cc protection rcquirementl eatabUIhcd UDder
MiMesola StalUtl:s;Chapttrl03H. . .
A:cxmpcert.for (BWSRIJJ 10117193)