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REPLACEMENT OF EXISTING NAVIGABLE STREAM CULVERT— EXEMPTION INFORMATION/RECORDS This worksheet can be used to request an exemption from DNR permits under chapter 30.123(6)(r)(a)Wis.Stats. DNR staff can-often meet onsite to help identify if a culvert may be vulnerable to flood failure,maintenance probleras,and/or ad- •r Project Name: Taylor Lane Culvert Existing Road Proposed Road Culvert size 30 inch 60 inch Culvert length 70 feet 74 feet Road top width 24 feet 24 feet (surface+shoulders) Road shoulder side slopes 3:1 3:1 (i.e. 2:1 or 3:1 slopes) Describe changes to culvert NA No Change elevation or slope. Will the road surface eleva- tion over the culverts be NA D Yes 1151No raised? Mark the appropriate box below if any of the following problems exist at the current culvert iThe culvert is perched above the streambed(i.e. waterfall at the outlet) CThere is a scour pool at the outlet CThere is water pooling on the upstream side of the road 7 Water can overtop the road during flood events E The culvert can get blocked with debris or there are beaver problems • Completion of this Information Worksheet will provide the WDNR with information to evaluate the proposed project.The Department will review the project proposal and site specific conditions to determine if the project is exempt from DNR culvert replacement permits.Depending on specific site condi- tions,your liaison may request further information.It is the applicant's responsibility to obtain all necessary local,state and federal permits and approv- als from the appropriate entities prior to construction.By signing below you are acknowledging that you have read this information and understand that further reviews may be needed to proceed with your project. The signer of this document is acknowledging they have the authority to represent the con- structing municipality, Signature&Title et - tv DateG7' 2