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State of Wisconsin Maintenance Dredging of a Previously Dredged Area <br /> Department of Natural Resources 9 9 General Permit 9 R1-07 <br /> www.dnrwi.gov Form 3500-108 page 4 of 8 <br /> Notice:This application form is required under Section 30206,Wis.Stats.and ch.NR 310,Wis.Adm.Code.Failure to submit a complete <br /> application to the Department at least 35 days prior to the date of proposed construction may result in dismissal of your application,forfeitures <br /> or other enforcement Personally identifiable information Included on this form will be used to contact you and is not intended to be used for <br /> other purposes.it may be made available to requesters under Wisconsin's Open Records law[ss.1931-1939,Wis.Stats.j. <br /> Section I:Landowner Information <br /> Nam <br /> uit` Contact Person <br /> Iiii r <br /> Lo m n + Ct Loll �f nic <br /> Mailing Address C Email Address . <br /> R(e(0-7 PA) V nui s l-i c-v4.1/e8 0 wilt( .Icy- .,,ci f <br /> City State Zip Phone Fax <br /> ai1 i( L;A-e- W.L._ 5 35_ ( Cos )(oil 3 -?Ss) ((,c,% ) (oi3-68 ig <br /> Section II:Activity <br /> Check the box next to the type of general permit youare requesting with this application <br /> ❑ Biological Shore Erosion Control ❑ Dry Fire Hydrant ❑ Pilings ❑ Riprap Repair/Replacement <br /> p pair/Replacement <br /> ❑ Boat Ramp ❑ Fish Habitat Structure ❑ Plant/Animal Nuisance Removal ❑ Seawall Replacement <br /> ❑ Clear Span Bridge ❑ Ford ❑ Pond-Landscape ❑ Seawall-Replace with Riprap <br /> ❑ Culvert <br /> ❑ Grading-Less Than One Acre ❑ Pond-Stormwater ❑ Temporary In-Stream Crossing <br /> ❑ Dredging-Drainage District ❑ Grading-One Acre or More ❑ Pond-Wildlife ❑ Wildlife Habitat Structure <br /> ❑ Dredging-Utility Crossings ❑ Intake/Outfall Structure ❑ Riprap RI,Other: <br /> Section III:Agent Information <br /> Check one L.1 Consultant L4Contractor Contact Person 3 <br /> 1Ai5 kil1J .r- <br /> U Authorized ScAeci Representative ❑Not Applicable N,5 cf-.04) <br /> Mailing Address . Address <br /> ')j)L4,5 ; ppte- RC( <br /> City State Zip Phone Fax <br /> .Saul," C;4 T 5 3S 3 (6)0S ) C cf 3 ..--t/j32( <br /> Section IV:Site Information <br /> Project Address Y/ Waterway Name <br /> fg5gi Crxin . ?fi <br /> 14/14 % Sectio' Township Rang 6W W Check one County <br /> .17a Di N ❑City ❑Town ❑village of <br /> sect Start Date Approximate Project End Date <br /> (Month/Day/Year) 1 c�- Io (Month/Day/Year) 1 a/0 d) <br /> Will this project effect wetlands? ❑Yes 4No ❑unsure / <br /> How did you arrive at this conclusion? tU repair O'ili.c. 8Cin4S .P, f lets <br /> c up f�r' loc �,�d irk rk 14ne, ci 4 is. 3WY <br /> 0-40'srd-aoa.8- Sq-9/f''9 <br />