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Stag Qf Wisconsin Maintenance Dredging of a Previously Dredged Area 4 <br /> Department of Natural Resources General Permit Packet R1-07 <br /> www.dnr.wi.gov Form 3500-108 page 6 of 8 <br /> Section VIII:Certification and Permission <br /> I am the owner of the riparian property or am the duly authorized representative and may sign this application on behalf of the <br /> owner(s)of said property.I hereby certify that the information contained herein is true and accurate.I have read and understand <br /> all of the conditions listed in this permit and in the instructions.I have designed the project to comply with the conditions,and I <br /> will construct the above-mentioned project in compliance with all such conditions.I hereby give the Department permission to <br /> enter and inspect the site at reasonable times,to evaluate this application and to monitor compliance with any resulting permit. <br /> I understand that failure to comply with any or all of the provisions of the permit renders the authorization contained herein null <br /> and void and may result in a fine and/or imprisonment or forfeiture under the provisions of ch.30.Wis.Stats. <br /> Landowner or Agent Name(please print) <br /> L D u�`S 1` /3'L uit i � <br /> Landowner r Agent Signature j� r/// Date Signed <br /> • 4,-Lf.- , ✓ /'�, <br /> 0 _ <br /> Mail this signed,compl form,along with all t nformation shown on our check lists,including three copies and the <br /> appropriate fee to the Department of Natural Resources office in the region where the project is located.See the instructions for <br /> regional office addresses. <br /> This permit application is approved when it is signed and dated below by an authorized Department of Natural Resources <br /> employee. <br /> Section IX:Permit Approval DNR USE ONLY <br /> Date Application Received Docket# Date Application Completed Fee Received <br /> sC <br /> ag--Ott 6P -02 0a-$7-7P /L-a -0, $ 50 <br /> ,N_,HII Checked? Historic Checked? ASNRI? a6;:: PRF? ,� PNW? ��/ <br /> ti Yes aces ❑Yes ❑Yes la No ❑Yes L�No <br /> State of Wisconsin Department of Natural Resources Title 6tM <br /> for theSecr- .r <br /> 4 Date Signed <br /> Issued b , ; <br /> /02 7-00 <br /> i <br /> Copies of this •ermit -nt to: ❑ Conservation Warden <br /> ❑ U.S.Army Corps of Engineers <br /> ❑ Zoning Administrator <br /> ❑ Town Clerk <br /> ❑ Other <br />