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55000260188002_Conditional Use Permits_09-19-2006
1008096 OFFICE OF COUNTY RECORDER OTTER TAIL MINNESOTA :a:re5!?ioo8096_was filed/recorded in this office for record, on/the .^^^day of (Oof___2006atl:f/^m/|3m ullity R l^ecording fe^ ^well certifirate lerWe by; THE ABOVE SPACE IS RESERVED FOR THE COUNTY RECORDER APPLICATION FOR CONDITIONAL USE PERMIT COUNTY OF OTTER TAIL GOVERNMENT SERVICES CENTER 540 WEST FIR, FERGUS FALLS, MN 56537 (218) 998-8095 Otter Tail County’s Website: www.co.ottertail.mn.us IHOSaB SIS^- Xi^-lOo^ Sic Si z. Application Fee COMPLETE THIS APPLICATION IN BLACK INK Receipt Numbeii_ Accepted By / Date Alien aiAti Ca^l ELlCftiiQ PROPERTY OWNER(S)DAYTIME PHONE n^ApllgS ff\P.OMAILING ADDRESS 56-93//e-pLAKENUMBERLAKE NAME LAKE CLASS TOWNSHIP NAME Sc R-fV\^( £ /gIVSECTION TOWNSHIP RANGE Qgi^y ^PARCEL NUMBER E-911 ADDRESS6^000 007^ LEGAL DESCRIPTION PT GL 3 COM NW COR SEC 26, S 234.57' TO PT BG, S 600.14', N 89 DEG E 764.25 ALG LK TO INTSEC LN BEARS N 89 DEG E FR PT BG, THENCE S 89 DEG W 913.4' TO BG /I.SoftCTO LK, NLY CONDITIONAL USE PROJECT REQUESTED (Please circle the appropriate request) Topographicai Aiteration__ Commerciai Use Forest Land Conversion Miscelianeous Cluster Development__ Extractive Use industriai Use SPECIFY YOUR REQUEST. PLEASE BE BRIEF AS THIS WILL BE USED FOR PUBLIC NOTIFICATION. 0.1 cat dnaae <x\au.a ^hweiikjX y. l(o^ fr hj 6Z f-f /> l>jPYoYi 0I05 "h) ^4 h)^cio "4^^ voiA duvi^ <5oci6, 6l(ifLuicC0uaKjk^ I UNDERSTAND THAT APPROVAL OF THIS REQUEST APPLIES ONLY TO THE USE OF THE LAND. I ALSO UNDERSTAND THAT OTHER PERMITS MAY BE REQUIRED, IT IS MY RESPONSIBILITY TO CONTACT LAND & RESOURCE MANAGEMENT REGARDING THIS MATTER. fiMw. Cl C^uA^j/k K SIGNATURE OF PROPERTY OWNER (S)DATE APPLICANT MUST BE PRESENT AT THE HEARING (Applicant Will Receive Notification As To The Date/Time Of Hearing) m.Date Of Planning Commission Hearing Time Planning Commission Motion October 11. 2006: Motion: A motion by Trites, second by Schwartz to deny for the following reasons: 1. Avoidance of the wetland impact is a more reasonable option given that 2 other lake access options exist. 2. Fill in this area has been previously denied. Chairman/Otter Tail County Planning Commission County Board Action Approved As Recommended Denied As Recommended Other it^jn jo(p Date of Filial ActionChairman/Otter Tail County Boa^of Commissioners kiat'€C L & R Official/Date CONDITIONAL USE PERMIT # ^ Permit(s) required from Land & Resource Management Yes (Contact Land & Resource Management)No ficiil/Date ~ Copy of Application Mailed to Applicant, Co. Assessor and MN DNR bk 0204-006 317,339 • Victor Lundeen Co., Printers • Fergus Falls, Minnesota OS CW 360 03A Tax parcel Number(s) Drawing must be to scale. Drawing shall identify project and include the setbacks to all of the existing and proposed lotlines, road right-of-way(s), ordinary high water level(s), structure(s), septice tank(s), drainfield(s), bluff(s) & wetland(s). Must also include all proposed topographical alterations. % Scale Impervious Surface hfofirn /* Rll line fir-I nice leoet Loujesf Ifivea. Loiihin 2<9 ' oi Id. irfdac It io depill Wads $ o/>l/ L>>U) X ^OXiS X hI/- Ay^a K tk.jidU ^ ^ „7S‘ l.5S' = 35 Ljcj^ 53 tycl3 33 <^(0 J17- 3S Lj d ^ 4 ^ - I ^ •r I 3,yo ^ *7S -ilfibjhr^ n.2^ci^ lS.5 X /7-i dI —jq •11 O o \ni^5+v3 loicj Surface, 37. ^ -------- "X .75 sv XVO >^.7S j lOZO^^ / Jl7 ^ / yoXfSx hS =^9ookI53y^3 1^“1% • fi 6"4: i/oX/5X 33^d lS~1oo^^VO K .s 3.\ 40 A . S / 33-5 X = l€)$o AfAC 55(jdiIb •' I I 6 2.'•^ol / -i5o£jLtA or p4Y/yvi Sf(>Z X l(pd' 10 X /b'> 35 X /(pc) /f Suy-fi f\fleAace J)on Schwedey has UiiicOeJi 4iu's A-fLeM ctvtfA adoiscd [\Q[^) do dthymine c,r|3 ol -Pill % flllL Ol. Signali/e of Property Owner (? ~H''0h Date BK — OSOS 322,180 • Viciof Lundeen Co. Primers • Fergus Fails. 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I I SEIM ?Gdi^n*U ' L ^ Peek 10 David JohnsonRodney IHagen Michael SuessS-NGE^Michael Johnson I ft Jill»rjKr.GeraldJtbbut%-152 aPatrick8021 A 804-^\?’I':' < iK.___ ^RANKt\l3'go 223fr»!uLaoTAMAP.'Clake cat) L 14 wMarilyn ' Fergestad eW 22f% IhCnhlcme^ll«Peck120 Kevin ft' Kevin Bakken 148iiiJLori5-I Bakken 160109 HMIdacIJohruon80PftDC tGordoi^r*^ Ernest Seidel 116 to 160JlV-4 34M*D MmcIi 2 Rodney ft 0*0 I* >i 2Ran‘"la22 Uan*«n P*i VickyBradford Amtson etal 138 Salftm Dairy Lcalle a S4*««B * Nancy C>t«ni Edward ft Beulah Amtson aA,JftDJ 11Ernest ft Gordon Seidel 80 nFlli V LDAV 30SaUarS Rot2 IM 90Peckso ard F' 2 160Patrick 1 Peck aajc 10 -J K*01. 10 > Clyde ftJwinti Hoadlcy in74Ralph* Marlon Hoadlcy T^- r53 0^ * Karen 1 Moiey 61 ggKenneth ft Donna Sather 160 P 20 93 Ernest ^ SeldeU KJ Leslie ft NancyI Delane •0 Berg Kenneth ftHelen Johnson 20 MarvinOlson807840Rotz37UfOD Deia*>-N Naaerkinn 341Stuart ft Roberta Restad 201 151Carla Johnson 1KeithAnderson160 80 Sn.807 hLt)a SackPm 40 2Linda Augustus Elisabeth ft Collin Daiid Alice Peckr ! q iO&O I Associates LLP 156 Ha^nid Rapids109 ' EngebretsonUSN*154 \160 -I Joan f Beyer 200 Loan Acres Ptnrshpd-------\94 I uaryi & Colette , Haugrud 6i \I 375Li tw431 2 , <§\35193 . Thomas ft Julie h Langseth / 198 DmmM* 1 1ir" "~Hi 69 Allen & Dorothy WaasorpQIKi.* (Dallas MotiManta kClaHa LorenSeifert .A*- il HtU(n>4 I-----f" miai& 226Orlean PaMda Rudle 79 Richard ft lift Haufnid ft !l 96WayneJohnson Bogenbrook80•0 l<0 Inci!r 40 210mm NORWEGIAN GROVE PAGE 92 PELICAN PAGE 108 GJTi ^^4 116 t; ft v5y*/z mi/<i 9 /IfiO) I uooa\^\ b& hftppt| 4o m.ee{ uj^io ^ou, aig' So?5 - IDOE IlfCLufi Q ou Aovtt veotli WU m«3sagc. v\umOKP li: if (Lo^ a DEPARTMENT OF THE ARMY ST. PAUL DISTRICT, CORPS OF ENGINEERS 190 FIFTH STREET EAST ST. PAUL, MN 56101-1638 RECEIVED FEB'ie 2007 LAND & RESOURCE February 8. 2007 REPLY TO ATTENTION OF Operations Regulatory (2006-5421-LAG) Mr. Allen Kuvaas Box 366 Pelican Rapids, Minnesota 56572 Dear Mr. Kuvaas: This concerns the Department of the Army (DA) permit application for your project fill 5600 square feet of wetlands adjacent to Tamarac Lake. The project site is in Sec. 26, T. 137N., R. 43W., Otter Tail County, Minnesota. We have been advised that this project has been denied the required Conditional Use Permit by the Otter Tail County Board of Commissioners. When a denial occirrs before a decision has been made on an application for a DA permit. Federal regulations allow the Corps to deny the permit without prejudice. This means that the applicant has the right to reinstate evaluation of the application if subsequent approval is received from the appropriate agency. Therefore, this DA permit application is denied. If you obtain approval firom the Otter Tail Land and Resource Office, we will, at your request, reinstate the evaluation of the application. If you have any questions, contact Leo Grabowski in our Brainerd office at (218) 829-8402. In any correspondence or inquiries, please refer to the Regulatory number shown above. Sincerely, a ----- Robert J. Whitirig Chief, Regulatory Branch Copy furnished: Otter Tail Land and Resource, Kyle Westergard otter Tail County, Planning Commission October 11, 2006, Page 5 “Kalpin Estates’Welna Dittbenner et al - Tabled To December 13. 2006: A Preliminary Plat titled "Kalpin Estates” consisting of 5 Single Family Residential lots, 1 Block and a Conditional Use Permit Application (as stated by the Applicant): Upgrade Public Road thru plat according to Appendix 3 of the Subdivision Controls Ordinance. The property is described as Pt GL 2, (1.68 AC), Section 27 and Pt GL 9 ....(6.48 AC), Section 28, of Parkers Prairie Township: Lake Adley (56-31), GD. Motion - September 13, 2006: A motion by Estes, second by Maske to table, at the Applicant’s request, to October 11, 2006, to allow the Applicant to provide a center line road profile: this information must be received by Land & Resource Management no later than September 22, 2006. Bill Kalar read a letter (dated September 19, 2006) from Brad Nyberg (Surveyor) requesting this Application be tabled to December 13, 2006. Motion: A motion by Boyer, second by Maske to table to December 13, 2006 as requested by the Applicant. Voting: All Members In favor. Clitherall Township / Richard Jibben - Approved As Presented: A Conditional Use Permit Application (as stated by the Applicant): Reconstruct approximately 1/3 mile of existing township road to correct drainage and safety concerns. Approximately 3,000 cubic yards of excavation/embankment will be utilized from within the right-of-way and adjacent borrow area. A 28 foot wide subgrade cross section will be constructed. Two (2) existing centerline culverts will be extended or replaced. The intersection of Statesboro Lane will be realigned to a right angle. Temporary and permanent erosion and sediment control measures will be utilized for all disturbed areas. The project is located on Statesboro Drive from 402"'* Avenue: east and north to the Girard Township line adjacent to parcel 10000010004800, Section 1 of Clitherall Township: West Battle Lake (56-239), GD. Jeff Stabnow represented the Application. Motion: A motion by Amo, second by Maske to approve as presented. Voting: All Members in favor. Allen & Carol Kuvaas - Denied: A Conditional Use Permit Application (as stated by the Applicant): Request to fill low area behind ice ridge along shoreline. The size of the area to be filled is 160 ft. x 8 ft. x 168 ft. x 62 ft. with a surface area of 5600 sq. ft. (±). Lowest depth of fill is 18 to 22” tapering to 0”. Fill material will be sandy clay taken on site from ridge near new building, approximately 205 to 220 yd^. Request to do this work during fall 2006. Application for Wetland fill has been made. The property is described as Pt GL 3, (11.80 AC), Section 26 of Scambler Township: Tamarac Lake (56-931), RD. Allen Kuvaas represented the Application. Motion: A motion by Trites, second by Schwartz to deny for the following reasons: 1. Avoidance of the wetland impact is a more reasonable option given that 2 other lake access options exist. 2. Fill in this area has been previously denied. Voting: All Members in favor. OTC Board of Commissioners’ Minutes October 17, 2006 Page 5 Preliminary Plat - “Pleasant Grove Second Addition”: Motion by Froemming, second by Mosher, and unanimously carried to approve the Preliminary Plat known as “Pleasant Grove Second Addition” consisting of 1 single family residential lot with conditions as recommended by the Planning Commission. The property is described as NWVi NE^/^ ex 150’ strip running fr SW cor to NE cor ...(29.45 AC), Section 32 of Amor Township: Otter Tail Lake (56-242). Preliminary Plat - “Red Lake Estates’/Lvie Vernon Danielson: Motion by Nelson, second by Block, and carried with Mosher opposed, to deny, as recommended by the Planning Commission, the Preliminary Plat known as “Red Lake Estates” proposed for 11 single family residential lots and a Conditional Use Permit to construct a road to service the proposed plat. The reason for denial was failure of the applicant to meet presentation standards for viewing. The property is described as Lots 1, 5 & 6 & SEVa SEYa Ex Cem. & Flowage, Section 34 of Friberg Township: Otter Tail River (56-OTR), AG: West Red River Lake (56-711), NE: Unnamed Lake (56-1132). Preliminary Plat - “Norway Estates’YABA LLC, Norway Beach Partnership: Motion by Mosher, second by Froemming, and unanimously carried to approve the Revised Preliminary Plat (received 10/11/06) known as “Norway Estates” consisting of 3 lots (2 single family residential backlots and a residential lot proposed for a Cluster Development) and a Conditional Use Permit to construct a road to service the proposed Plat. The approval is subject to conditions as recommended by the Planning Commission. The property is described as Pt of GL 1 (4.82 AC & 5.00 AC) and Lots 1 - 7 of Norway Beach, Section 34 of Tordenskjold Township: Stalker Lake (56-437). Conditional Use Permit - Norway Beach Partnership/Brian Hartman & Arivn Hustad: Motion by Mosher, second by Nelson, and unanimously carried to approve a Conditional Use Permit for a 6 unit Common Interest Community to change usage from resort status to single family residential use with conditions as recommended by the Planning Commission. The property is described as Pt of GL 1 (4.83 AC) & (5 AC) and Lots 1 - 7 of Norway Beach, Section 34 of Tordenskjold Township: Stalker Lake (56-437). Conditional Use Permit -Clitherall Township/Richard Jibben: Motion by Mosher, second by Block, and unanimously carried to approve a Conditional Use Permit to reconstruct a portion of an existing township road as presented. The project is located on Statesboro Drive from 402"'^ Avenue: east and north to the Girard Township line adjacent to parcel 10000010004800, Section 1 of Clitherall Township: West Battle Lake (56-239). Conditional Use Permit - Allen & Carol Kuvaas: Motion by Lee, second by Block, and unanimously carried to deny, as recommended by the Planning Commission, a Conditional Use Permit to fill low area behind the ice ridge along the shoreline. The reasons for denial are as identified in the October 11, 2006, Planning Commission minutes. The property is described as Pt GL 3, (11.80 AC), Section 26 of Scambler Township: Tamarac Lake (56-931). OTTER TAIL COUNTY PLANNING COMMISSION NOTICE OF PUBLIC HEARING APPLICANT:Allen and Carol Kuvaas PO Box 366 Pelican Rapids, MN 56572 HEARING DATE/LOCATION: October 11, 2006 at 8:30 P.M. ** Commissioner's Room, Government Services Center West Fir Fergus Falls, MN 56537 CONDITIONAL USE PERMIT APPLICATION REQUEST (as stated by the Applicant): Request to fill low area behind ice ridge along shoreline. The size of the area to be filled is 160 ft. x 8 ft. X 168 ft. X 62 ft. with a surface area of 5600 sq. ft. (±). Lowest depth of fill is 18 to 22” tapering to 0”. Fill material will be sandy clay taken on site from ridge near new building, approximately 205 to 220 yd^. Request to do this work during fall 2006. Application for Wetland fill has been made. LAKE NAME/NUMBER/CLASS: Tamarac Lake (56-931), RD E-911 ADDRESS: 48026 Co Hwy 9 LEGAL DESCRIPTION: Pt GL 3 ... (11.80 AC), Section 26 of Scambler Township ** Weather Conditions may change the Hearing date and time. If bad weather occurs, please listen to the local Fergus Falls Radio Stations or contact the Land & Resource Management Office, by 4:30 p.m., for possible rescheduling of the Hearing. The above Applicant has made Application to the Otter Tail County Planning Commission for a Conditional Use Permit as per the requirements of the Shoreland Management Ordinance of Otter Tail County. Details of the Application are available for viewing at the Land & Resource Management Office, Government Services Center 540 West Fir, Fergus Falls, MN 56537. Any comments regarding this request may be expressed at the Hearing or mailed to the Land & Resource Management Office at the above address. INDIVIDUALS REQUIRING SPECIAL ACCOMMODATIONS SHOULD CONTACT THE LAND & RESOURCE MANAGEMENT OFFICE PRIOR TO THE HEARING. September 27. 2006 Mailing Date Bert Olson Chairman Planning Commission LAND AND RESOURCE MANAGEMENTOTTER TAIL COUNTY COURTHOUSE, FERGUS FALLS, MN 56537 STATE OF MINNESOTA ) ) ss COUNTY OF OTTER TAIL ) I, Marsha Bowman, duly appointed and Acting Secretary of the Otter Tail County Planning Commission for Otter Tail County, Minnesota, do hereby certify that on thp _day of , 2006, the attached Notice of Hearing and was duly served upon the following: County Sheriff County Highway Engineer Courthouse Otter Tail COLA, John Matteson, 23562 W Silver Lk Rd, Battle Lake, MN 56515 MPCA, 116 E Front St., Detroit Lakes, MN 56501 Terry Lejcher, DNR, Div. of Waters, 1509 1st Ave N, Fergus 1221 Falls, MN 56537 Bruce Winterfeldt, DNR, Trails & Waterways Arlin Schalekamp, DNR, Div. of Fisheries Doug Hedtke, DNR, Div. of Wildlife (The above 8 receive all Notices) Lake Improvement District (if project is located on their lake, mail Notices to the Lk Imp Dist) Pelican, Fi^, Bass & Little Pelican: Pelican Group Lake Imp. Dist., %Fred Manuel, 26271 Otoson RD, Detroit Lakes MN 56501 South Turtle^ke: South Turtle Lake Imp. Dist., %Bricker & Janet Johnsen, 32790 Turtle Shore Ln, Undenwood, MN 56586 Little Pine Pine: Pine Lakes Imp. Dist, PO Box 405, Perham, MN 56573 \ Little McDonald, Kerbs & Paul: McDonald Lakes Imp. Dist., PO Box 133, Perham, MN 56573 CityyClerk (if located within 2 miles of a city) MNDQTDist. Office, 1000 Hwy 10 W, Detroit Lakes, MN 56501 (if located on a State or Fed Hwy) Same Envelope ^^pianr^q Commission Me^nber^lffownship ClerjjiCLake Associatiqr>/ sur^yor (if appropriate), ^*~an(J those llsleil uii the attachetfsheet..., by placing a true and correct copy thereof in a sealed envelope, postage prepaid, and by depositing them in the U.S. Mail at Fergus Falls, MN, properly addressed to each of the above named at the addresses shown above. Secretary Amj If parcel owner is “USA”, mail to Fish & Wildlife Service, 21932 St Hwy 210, Fergus Falls, MN 56537 If parcel owner is “DNR”, ignore as they are receiving a notice as stated above If parcel owner is “St. of MN. 375 Centennial Bldg. Spec Asst, to Atty General St. Paul, MN “, mail to DNR Lands & Minerals 2115 Birchmont Beach Rd NE Bemidji, MN 56601 PC Affidavit (4/06) PLANNING COMMISSION NOTIFICATION WORKSHEET (1/4 Mile for Conditional Use Apps /14 Mile for Preliminary Plats) : //. 9^06, ^0, -ou_____ Applicant; Lake: S Meeting Date: ^4Assigned To:Date Assigned: mft 27s,Completed:Return By: Townships / Sections / Plats: Ta1-P_ C.lev'lC l^hOLp S'-j f-c\[cun ^jViprcls^ /HaI /2- A5<yDC\cx]noin ^ckch l^d: Pdican^xf-prclsy 6U‘=^7;0 Page 1 of 1OTC Parcel Map Output Otter Tail County Parcel Viewer Map http://www.ottertailcounty.net/servlet/com.esri.esrimap.Esrimap?ServiceName=parcelscou... 9/22/2006 (2) LIST PARCELS IN BUFFER 9/22/2006 ■ Fields Sortname Street Addr Addr2 CSZ iFARGO ND 58102 162755000260185000 iANDERSON,EDWARD O III ET AL 201 29TH AVE N J 55000220159001 jBURTON,THOMAS & M ONEILL 5566622616360O 48377 PIKE BEACH TRL 143 OOTSTmA WAY PELICAN RAPIDS MN 56572 702 jLOUDONTN 37774 2819 PO BOX20M |MINNEAPOLisl^^^ jpELICAN RAPIDS MN 56572 702 jPBJCAN F^pTdsIw^ Ip^iCAN^PIDS IWM 56572 702” 55000230169000 GRIMSTAD,STEPHEN G 550062^1^6^ HAWs^EG6rY& SARAH 48030 COUNTY HIGHWAY 9 HAYES,GREGORY & SARAH 48030 COUNTY HIGHWAY 955000230169002 55666236T6966T HAYES,GREGORY & SARAH 48030 COUNTY HIGHWAY 9 HOADLEY,RALPH H & MARION JOUBERf^'jERALDTDARlENE” i^MP,M4SsiHA ^LMER KUV/^S,ALLEN NELY6n,LA^RNE J & DA\ADF 19383 473RD ST 42? 4TH~AVE NW 421?4TH^e1nW ;PELICAN RAPIDS MN 56572 703 IBARNESVTlLe MN“56514“3129 ' IBARNESvTlLE MN 565143129 PO BOX 366“IPELiCAN RAPIDS MN 56572 366 [PELICAN ^PIDS MN 56572 762’ PO BOX 236 |f REVOR Wl 53179 236 [pelican ^^s mn“ 56572762 jPELICAN RAHDS MN 1^2702 55000270193000 55666266188666 55666266188664 I ! 55000260188002 47812 COUNTY HIGHWAY 955000260188003!PERRET,DONALD F & JOANNE C PEfZNICK,JADE&IiSA H^GRU^ 55000270197000 5566626618866?48026 COUNTY HIGHWAY 9 55000230169004 PETZNICK,JADE 8. LISA HAUGRUD 48026 COUNTY HIGHWAY 9 Page 1 NA-026620-1 (V.2.02 for MS WORD) 10/29/04 Minnesota Locai/State/f edefarAp^ication Forms for Water/Wetland Projects USE THIS APPLICATION FOR ANY PROJECT AFFECTING A LAKE, RIVER, STREAM OR WETLAND, INCLUDING: Local Government Unit Approval Pursuant to Minnesota Wetlands Conservation Act (WCA) Minnesota Department of Natural Resources (DNR) Permit to Work in Public Waters Department of the Army Permit (33 CFR 325) Note: The U.S. /\rmy Corps of Engineers (COE) will forward application forms to the Minnesota Pollution Control Agency flPCA) for processing if state water quality certification is required from the MPCA. Youdo not need to send this application to the MPCA. This application packet includes : Part I: The BASIC APPLICATION and the COE APPLICATION to be filled out by all applicants (see Instructions). PART II: The REPLACEMENT PLAN SUPPLEMENT to be completed only for projects that impact wetlands and-require a replacement plan for wetland mitigation. If you’re not sure wHbther your project requires a replacement plan, call your Local Government Unit (LGU) or Soil and Water Conservation District (SWCD) office for guidance. Do not proceed with your project until you have received all required approvals from your LGU, the DNR and the COE. If you wish to confirm the status of your application at any time, contact the agencies directly (see Instructions, page 2). Proceeding with work before all required authorizations are obtained may result in fines or other penalties, and may include a requirement to restore the project sitectoriginal condition. If you have questions or need assistance with filling out these forms, contact your local SWCD office, your LGU, your Area DNR Waters office, or your COE field office (see Instructions, page 2). If you believe that your project may be subject to watershed districtjocal zoning, or any other local regulations besides those of your LGU, contact those office(s) directly. If you are a Federal Farm Program participant and your project affects a wetland or water body on agricultural land, your eligibility for USDA benefits may be affected. Contact a Natural Resources Conservation Service office for further information. A QUICK LOOK AT THE PROJECT APPLICATION PROCESS Electronic files: Forms can be downloaded and filled out using Microsoft Word. Your input will be restricted to fill-in fields where users can enter text or check boxes. These areas appear gray on the screen, but not on the printed document. Send copies of these completed application forms to your LGU, your Area DNR Waters office, and your COE regulatory office. Any of the agencies may make initial contact with you to: a) inform you that it has no jurisdiction over your project; b) request additional information needed; or c) inform you of applicable fees. When your application is considered complete and appropriate fees have been received (if requested) it will be distributed foppropriate review. Following agencies’ reviews, you will be informed if it has been approved, approved with changes or conditions, withdrawn, oedied. For information about state laws, rules and regulations that direct this process go to the web site www.revisor.leg.state.mnufor information on U.S. Army Corps of Engineers regulations go to the web site www.mvp.usace.army.mil. Instructions for Part I HELP 1: Every applicant must fill out Section 1. The applicant is the person, agency, company, corporation, or other organization that owns, leases, or holds other legal rights to the land where the project is located. Indicate names of multiple applicants on a sepate sheet. HELP 1 A: Fill out Section 1A only if you have designated an authorized agent. An authorized agent may be an attorney, builder, consultant, contractor, engineer, or any other person or organization designated by the applicant to represent him/her in this process. Aagent is not required. HELP 5: Purpose, description and dimensions of project: State briefly (in a sentence or two) what you propose to do and why it is needed. Also, describe whether your project will involve any of the following: - Construction of structures, filling, draining, dewatering, removing, excavating or repair. - Construction of an access path, bridge, culvert, dam, ditch, dock, driveway, riprap, road, sand blanket, shore protection, dtle line. - Construction of any structures on fill, piles or a float-supported platform. If so, describe. - Dredging or discharging (placing fill material) into a wetland or other water body (including the temporal^' ptement of material). If so, explain the specific purpose of the placement of the material (such as erosion control) and indicate how it will bdone (such as with a backhoe or dragline). If dredged material is to be discharged on an upland site, identify the location of the site. Minnesota Local/State/Federal Application Forms for Water/Wetland Projects Instructions, Page 1 1» ^CMUU) fc. APPLICATION FOR DEPARTMENT OF THE ARAH PERMIT (33 CFR 325)0MB APPROV AL NO. 0710-003 Expires Dec 31, 2004 The public burden for this collection of information is estimated to average 10 hours per response, alllioiigh the majority of applications should require 5 hours or less. This includes the lime for reviewinu instructions, searchitiu existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of infonnaiion. including suggestions for reducing this burden, to Department of Defense. Washington Headquaners Service Directorate of Information Operations and Reports. 1215 JefTerson Davis Highway. Suite 1204. Arlington. VA 22202-4302; and to the Office of Management and Budget. Paperwork Reduction Project (0710-0003). Washington, DC 20503 Respondents should be aware that notwithstanding any other provision of law. no person shall be subject to any penalty for failing to compK' with a collection of information if it does not display' a currently valid 0MB control number. Please DO NOT RETURN your form to eithei of these addi esses Completed applications must be subndtted to the Disuici engineer having jurisdiction over the location of the pioposed activit). PRIV.ACN’ act STATEMENT: Authorities; Rivers and Harbors .Act. Section 10. 33 USC 403; Clean W’ater Act. Section 404. 33 USC 1344; Marine Protection. Research and Sanctuaries Act. 33 USC 1413. Section 103. Principal purpose; Infonnaiion provided on this form will be used in evaluating the application for a permit. Routine uses; This information may be sltared with the Department of Justice and other Federal, state, and local government agencies. Submission of requested infomiation is voluniar>‘; however, if information is not prot'ided. the permit application cannot be evaluated nor can a pennit be issued ITEMS 1 THROUGH 4 TO BE FILLED IN BY THE CORPS 2 FIELD OFFICE CODE 3 DATE RECEIVED 4. DATE APPLICATION COMPLETEDI. APPLICATION NO. YOU DO NOT NEED TO COMPLETE ITEMS 6-10 and 12-25 in the SHADED AREAS. All applicants must complete non-shaded items 5 and 26. If an agent is used, also complete items 8 and 11. This optional Federal form is valid _______________________________for use only when included as part of this entire state application packet._________________'■_____________ 8. AUTHORIZED AGENT’S NAME AND TITLE (an agent is not required)5. APPLICANT’S NAh^ 6. APPLICANT’S ADDRESS 9. AGENT’S ADDRESS 7, APPLICANT’S PHONE NO.10. AGENT’S PHONE NO. II. STATEMENT OF AUTHORIZATION (:/ applicable: completeon\y if authorizing an agent) I hereby authorize supplemental information in support of this permit application. to act on my behalf as my agent in the processing of this application ando furnish, upon request, DATE:APPLICANT’S SIGNATURE; 12. PROJECT NAME OR TITLE (see instructions) 13. NAME OF WATERBODY, IF KNOWN (if applicable)14. PROJECT STREET ADDRESS (if applicable) 15. LOCA'nON OF PROJECT 16. OTHER LOCATION DESCRIPTIONS, IF KNOWN (see instructions) 18. NATURE OF ACTIYITY17. DIRECTIONS TO THE SITE 20 REASON(S) FOR DISCHARGE19. PROJECT PURPOSE 21. TYPES OF MATERIAL BEING DISCHARGED AND THE AMOUNT OF EACH TYPE IN CUBIC YARDS 22. SURFACE AREA IN ACRES OF WETLANDS OR OTHER WATERS FILLED 23. IS ANY PORTION OF THE WORK ALREADY COMPLETE? YES NO___IF YES, DESCRIBE COMPLETED WORK. 24. ADDRESSES OF ADJOINING PROPERTY OWNERS, 25. LIST OF OTHER CERTIFICATIONS OR APPROVALS/DENIALS RECEIVED FROM OTHER FEDERAL, STATE OR LOCAL AGENCIES FOR WORK DESCRIBED IN THIS APPLICATION. 26. Application is hereby made for a permit or permits to authorize the work described in this application. I certify that the information in this application is complete and accurate. I further certify that I possess the authority to undertake the work described herein or am acting as the duly authorized agent of the applicant. //?/'/11/ Signature of agent (if any)Signature of applicant Dale Dale The application must be signed by the person who desires to undertake the proposed activity (applicant), or it may be signed h>du)y authorized agent if the statement in Block 1 1 has been filled out and signed. 18 U.S.C Section 100J>rovides that: Whoever, in any manner within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals, or covers up with any trick, scheme, ctisguises a material fact or makes any false, fictitious or fraudulent statements or representations or makes or uses any false writing or document knowirrame to contain any false, fictitious or fraudulent statements or enir\'. shall be fined not more than $ 10.000 or imprisoned not more than five vears or both. EDITION OF FEB 94 IS OBSOLETE.ENG FORM 4345, Jul 97 (Proponent: CECW-OR) Minnesota Local/Slate/Federal Application Forms for WaterAVetland Projects Page 2 FOR LGU USE ONLY: □ No WCA Jurisdiction r~l Exempt: No.___(per MN Rule 8420.0122) □ No Loss: ___(A.B,. . .G, per MN Rule 8420.0220) □ Replacement required - applicant must complete Part II Determination Tor Part I: COMPLETE THE SECTION BELOW ONLY IF REPLACEMENT IS NOT REQUIRED: Application is (check one): Q Approved □Approved with conditions (conditions attached) □ Denied Comments/Findings: LGU official signature Date Name and Title For Agricultural and Drainage exemptions (MN Rule 8420.0122Subps. 1 and 2B), LGU has received proof of recording of restrictions (per MN Rule 8420.0115): County where recorded Date Document it assigned by recorder LGU official signature Date Minnesota Local/State/Federal Application Forms for WaterAVetland Projects Page 3 (V.2.02 for MS WORD) 10/29/04 Minnesota Local/State/Federal Application Form for WaterAA/etland Projects NA-026620-03B For Internal Use Only Date Initial Application Received Date initial Apptation Deemed CompleteField Office CodeApplication No. PART I: BASIC APPLICATION “See HELP” directs you to important additional information and assistance in Instructions, Page 1. 1. LANDOWNER/A^LICANT CONTACT INFORMATION (See Help I)/I Men f^ut/oas Ui' iootPhone:Name: Complete m^ing address: ,UO fy\'my, 5(c5npi os lA. AUTHORIZED AGENT (See Help lA) (Only if applicable: an agent is not requireef Phone:Name: Complete mailing address: 2. NAME, TYPE AND SIZE OF PUBLIC WATERS or WETLANDS IMPACTED (Attach Additional Project Areasheets if nseded) Name or l.D. # of Waters Impacted (if applicable; if known): > (Check all that apply): QUake nRiver 0Wetland typeQ 1 Q IL [0^ □ 3 Q4 QS Q6 Q? DS Indicate size of entire lake or wetland (check one): E^Less than 10 acres (indicate size:) □ 10 to 40 acres d Greater than 40 acres 3. PROJECT LOCATION (Information can be found on property tax statement, property title or title insurance): Project street addres5: ^% Section: Oilt* ^ection: Township#: /37 Lot#: (&L-3 Block: Attach a simple site locator map. If needed, include on the map written directions to the site from a known location or landmark, and provide distances from known locations. Label the sheet SITE LOCATOR MAP. Fire #:City (if applicable): County: Qficytui C Watershed (name or #) 5*^ UTM location: N Range #: Subdivision:E rC-y J / 4. TYPE OF PROJECT: Describe the type of proposed work. Attach TYPE OFPROJECT sheet if needed. Fill /T b^hiPtcf CU Xce Im/cp Slrjoy^ 5. PROJECT PURPOSE, DESCRIPTION AND DIMENSIONS: DescriBe what you plan to do and why it is needed, how you plan to construct the project with dimensions (length, width, depth), area of impact, and when you propose to construct the projectThis is the most important part of your application. See HELP 5 before completing this section; see What To Include on Plans (Instructions, page 1). Attach PROJECT DESCRIPTION sheet. square feet drained, filled or excavated.Footprint of project:acres or 6. PROJECT ALTERNATIVES: What alternatives to this proposed project have you considered that would avoid or minimize impacts to wetlands or waters? List at least TWO additional alternatives to your project in Section 5 that avoid wetlands (one of which may be “no build” or “do nothing”), and explain why you chose to pursue the option described in this application over these altematives^ttach PROJECT ALTERNATIVES sheet if needed. L Dc E>C-VVVlV3^ j CtlLSxdPk OptUMS Z. pvLj?i.rvin 7. ADJOINING PROPERTY OWNERS: For projects that impact more than 10,000 square feet of water or wetlands, list the complete mailing addresses of adjacent property owners on an attached separate sheet. (SeHELP 7) 8. PORTION OF WORK COMPLETED: Is any portion of the work in wetland or water areas already completed?!!] Yes ^No. If yes, describe the completed work on a separate sheet of paper labeledVORK ALREADY COMPLETED. (See HELP 8) 9. STATUS OF OTHER APPROVALS: List any other permits, reviews or approvals related to this proposed project that are either pendingir have already been approved or denied on a separate attached sheet. See HELP 9. 10. I am applying for state and local authorizationto conduct the work described in this application. I am familiar with the information contained in this application. To the best of my knowledge and belief, all information in Part I is true, complete, and accurate. 1 possess the authority to undertake the work described, or 1 am acting as the duly authorized agent of the applicant. //(C. 0 Signature of agent (if applicable)Signature of applicant (Landowner)Date Date This block must be signed by the person who desires to undertake the proposed activity and has the necessary property' rights do so. If only the Agent has signed, please attach a separate sheet signed by the landowner, giving necessary authorization to the Agent. Minnesota Local/Slate/Federal Application Forms for Water/Wetland Projects Page I Include an overhead view drawing showing the work to be undertaken and its relative location on the propertyShow items such as property boundaries or lot dimensions; location and extent of shoreline, wetlands and water; location and dimensions and footprint of the proposed project, structure or activity (include length, width, elevation and other measurements as appropriate); points of letfence such as existing homes, structures, docks or landscape features; indication of north; and location of spoil and disposal sites (if applable). Hand drawn, computer generated or professionally prepared drawings are acceptable, as long as they contain all necessary infomiation clearly, accurately, and in adequate detail. Please include specific dimensions whenever possible. You may also include photos, if you wish. Papeiopies should be limited to maximum dimensions of 11" by 17". Computer files should be viewable in a PDF format; contact the agency for other usable formats. HELP 7: For information regarding adjacent landowners, contact the tax assessor w'here the project is to be developed. HELP 8: If any part of the work has already been completed, describe the area already developed. Include a description of structures completed; any dredged or fill material already discharged (including type of material and volume in cubic yards); acres or square feet filled (if a wetland or other waterbody); and whether the work was done under an existing permit (if so identify the authorization, if pefcle). HELP 9: Other permits, reviews or approval related to the project may include the followingtconditional use permit; plat approval; zoning variance; National Pollutant Discharge Elimination System permit; state disposal system permit (includes dredged materlalisposal); watershed district/watershed management organization permit (stormwater, erosion, floodplain); environmental assessment worksheet/environmental impact statement; hazardous waste site; feedlot permit; groundwater appropriation permit; or county/towYiship driveway/road permit. Are you aware of any archeological or cultural resource determinations or surveys completed concerning the project or replacement site by the State Historic Preservation Office (SHPO) or others? If yes, please explain on a separate sheet or attach a copy of any determinations or surveys. Final Checklists (Part I) O Have you completed all of Part I (Page 1), plus the Federal application (Page 2)? EH Did you (and your agent, if applicable) sign Section lOon page I? n Have you signed the Application for the Department of the Army Permit (Page 2) to seek Federal authorization of your project? r~l Have you included the necessary attachments for Part P Attachments must include: EH Site Locator Map (Section 3) EH Type of Project (Section 4) (if additional space was needed) EH Overhead View of Project (Section 5 and HELP 5) EH Project Purpose, Description and Dimensions (Section 5) (if additional space was needed) Attachments may also include: EH Applicant Contact Information (HELP 1) (if additional space was needed) EH Project Location (Section 3) (if additional space was needed) EH Project Alternatives (Section 6) (if additional space was needed) EH Photographs EH Adjoining Property Owners (Section 7) (if additional space was needed) EH Work Already Completed Section (Section 8) (if you answered YES) EH State Historic Preservation Office determination or survey Submitting Your Application Make three copies of the entire application and all attachments. Keep the original, and mail a complete copy of your application to each of the local, state, and Federal entities listed below. Be sure to include Part I and all attachments with each application. LOCAL: Send to the appropriate Local Government Unit (LGU). If necessary, contact your county Soil and Water Conservation District (SWCD) office or visit the Board of Water and Soil Resources (BWSR) web site (www.bwsr.state.mn.us) to determine the appropriate LGU. STATE: Send to your Area DNR Waters office, attention Area Hydrologist. If necessary, contact your county Soil and Water Conservation District (SWCD) office or visit the DNR website (www.dnr.state.mn.us) to locate the Area Hydrologist for your location, or contact a Reignal DNR office: NW Region: 2115 Birchmont Beach Road N.E. Bemidji, MN 56601 Phone: 218-755-3973 NE Region: 1201 East Highway 2 Grand Rapids, MN 55744 Phone: 218-327-4416 Central Region: 1200 Warner Road Southern Region: 261 Highway 15 South NewUlm, MN 56073 Phone: 507 359-6053 St. Paul, MN 55106 Phone: 651-772-7910 FEDERAL: Send to the appropriate U.S. Army Corps of Engineers regulatory' field office: Brainerd: U.S. COE, Regulatory Branch 10867 E. Gull Lake Drive N.W. Brainerd. MN 56401-9051 Phone: 218-829-8402 St. Paul: U.S. COE, Regulatory Branch Army Corps of Engineers Centre 190 5^ Street East St. Paul. MN 55101-9051 Phone: 651-290-5375 La Crescent: U.S. COE, Regulatory' Branch 1114 South Oak Street Two Harbors: U.S. COE; Regulatory Branch 1554 Highway 2, Suite 2 La Crescent, MN 55947-1338 Two Harbors, MN 55616 Phone: 218-834-6630Phone: 507-895-8059 WEB SITES: BWSR: www.bwsr.stale.mn.us U.S. ACOE: mvw.mvp.usace.army.mil DNR: w'w'w.dnr.state.mn.us MPCA: www.pca.staie.mrus Minnesota Local/State/Federal Application Forms for Water/Wetland Projects Instructions, Page 2 Instructions For Part II Complete those portions of Part II: Replacement Plan Sipplement for which information is readily available (such as location, existing land use. size of impact area, etc.) A person certified in wetland delineation must determine items pertaining to specific w'etland impacts (wetland type, predominant vegetation, watershed name, etc.) Contact the local soil and water conservation district (SWCD) office for furthanformaiion on obtaining such items. What to Include on Plans Detailed overhead views of replacement site(s) (Part II), as well as profile view(s) of replacement site(s) (Part II), may be idler hand drawn, computer generated or professionally prepared, as long as they contain all necessary information clearly, accurately, and in adequate detail. Please include specific dimensions whenever possible. You may also include photos, if you wish. Overhead viewsof Part 11 replacement site(s) diould include the following items that pertain to your project: Property boundaries and/or lot dimensions. Location and extent of shoreline, wetlands and water. Location and dimensions of proposed project, structure or activity. Include length, width, elevation and other metisurements ^propriale. Points of reference (such as existing homes, structures, docks or landscape features). Location of inlet and outlet structures. Indication of north. Location of spoil and disposal sites (if applicable). Areas of wetland and upland plants established. Profile views (side or cross-sectional views) should include the following items that pertain to your project: Location and dimensions of proposed project, structure or activity. Include elevation, depth, soil profile, side slope and oth measurements as appropriate. Proposed water level elevation. Final Checklists Part II: Replacement Plan Supplement □ Have you completed all of Part II (pages 3-5)? n Did you (or your agent) sign Section 19on page 5? O Have you included the necessary attachments for Part II? Attachments must include: r~l If the project includes any wetland banking(compIete or partial), include Application for Withdrawal of Wetland Credits Form (Section 14) [~l If the project includes any project-specific replacements)complete or partial), include: Description of Replacement Wetland(s) Construction (Section 15) Copy of vegetation management plan (Section 15) Scale drawing of overhead view or replacement wetland (Section 18) Scale drawing of profile view of replacement wetland (Section 18) Attachments may also include: r~l Additional description of Wetland Impact Charts (Section 11) (if additional space was needed) □ Additional Description of Replacement Wetlands charts (Section 17) (if additional space was needed) □ Additional soils information for created replacement wetland(s) (Section 18) (if available) Note: To deposit surplus wetland credits in the State Wetland Bank, submit a Wetland Banking Application directly to your LGU (Sekan 16). Preparing Your Application for Mailing [m To apply for both state and Federal authorization, your application must include Part 1 (Page l)the Federal application (Page 2),and attachments as indicated on Final Checklist for Part /(Instructions, Page 2). CD Your application must also include Part II (Pages 3-5) and additional attaehments as indicated on Final Checklist for Part H (above). CD Make three copies of the entire application and all attachments. Keep the original, and mail the three copies to the appropriate local, state, and Federal agencies (see Instructions for Part 1 for addresses). Minnesota Local/State/Federal Application Forms for Water/Wetland Projects instructions Page 3 PART II: REPLACEMENT PLAN SUPPLEMENT For assistance in completing Part II. contact yotir Local Government Unit or a professional consultant 11. DESCRIPTION OF WETLAND IMPACTS: Complete the chan below: 1) Use one row of boxes for each wetland impact; 2) If your project has more than one wetland impact, reference your overhead view (pan of Section 5) to this chan by identifying and labeling “first impd’ and "second impact” on your overhead view; 3) If you are identifying only one wetland type within a given wetland impact area, use the first dotted line and leave thehers blank: 4) If you have chosen to identify more than one wetland type within a given wetland impact area, use the extra dotted lines indicate each wetland type, and identify predominant vegetation and size of impacted area for each separate wetland type within that impact area; 5) If you do not have access to some of this information, call your LGU or SWCD office for assistance.(Photocopy chart for more impacts, if needed.) DESCRIPTION OF WETLAND IMPACTS Wetland type^Predominant vegetation in impacted wetland area Wetland impact (as noted on overhead view) Watershed name or number (if known) County, Section, Township, Range Size of area impacted (in acres or square feet) Existing land use in project area (check all that apply) □ Housing □ Commercial □ Industrial G Parks/recreation areas □ Highways and associated rights-of-way □ Forested □ Farmsteads/agricultural [^Vacant lands □ Public and semi-public (schools/gov’t facilities) □ Airports □ Extractive (gravei pits/quarries) □ Other: (leaA Ccruo^^ yj/Aj... OH^vtrtil 5m ^ d2(pFirst impact ScAmbley13? 43 Second impact 'if you are identifying only one wetland type within a given wetland impact area, use the first dotted line and leave the othehSank. If you have chosen to identily more than one wetland type within a given wetland impact area, use the extra dotted lines to indicate each separate wetland type, elridentiiy predominant vegetation and size of impacted area for each separate wetland type with that impact area. TOTALS OF AREA(S) IMPACTEOFOR EACH WETLAND TYPE ON CHART [indicate acres\J or squarefeetST 7:Type: 12. SPECIAL CONSIDERATIONS: Are you aware of any special considerations that apply to either the impact site(s) or the replacement site(s)Q Yes 0^o (Examples: the presence of endangered species, special fish and wildlife resources, sensitive surface waters, or waste disposalte.) If YES, list and describe briefly. 1:IL:4;5: 6:8:R.. 13. SHORELAND IMPACT ZONE: Please identify each wetland impact site noted in Section 15 that is within 1000 feet of a lake or 300 feet of a river. in inipaci zoH^This pTQecf 15 Minnesota Local/State/Federal Application Forms for WaterAVetland Projects Page 4 14. HOW PROPOSED REPLACEMENT WILL BE ACCOMPLISHED: Indicate how proposed replacement will be accomplished (check only one box below and continue as indicated): D A, Wetland banking only Complete Application for Withdrawal of Wetland Credits Form and include with your application. Copies of this form are available from your LGU, or download a copy from www.bwsr.state.mn.us Skip to Section 19, page 6 (You do not need to complete Sections 15-18). [^B. Project-specific replacement only Continue with Section 15 below. D C. A Combination of wetland banking and project-specific replacement Complete Application for Withdrawal of Wetland Credits Form and include with your application. Copies of this form are available from your LGU. or download a copy from www.bwsr.state.mn.us Continue with Section 15 below. 15. DESCRIPTION OF REPLACEMENT WETLANDfS) CONSTRUCTION (Complete this section only if you marked Box B or Box C in Section 14 above): Describe in detail how replacement welland(s) will be constructed. If several methods will be used, describe each method. Ettils should include the following: I) type of construction (such as excavated in upland, restored by tile break, restored by ditch block or revegetat^cE) type, size and ‘ specifications of outlet structures; 3) elevations relative to Mean Sea Level or established benchmarks or key features (sucisaill, emergency overflow or structure height); 4) what best management practices will be implemented to prevent erosions or site degradation; 5) proposednetable for starting and ending the project; and 6) a vegetation management plan. Write this description on a separate sheet of paper \^he\eE>ESCRIPTION OF REPLACEMENT WETLAND CONSTRUCTION 16. SURPLUS WETLAND CREDITS; If using project-specific replacement (Box B or Box C in Section 14 above), will the replacement result in any surplus wetland credits that you wish to have deposited in the Slate Wetland Bank for future useQ Yes D No. If yes, submit a Wetland Banking Application directly to your LGU. Copies are available from your LGU. or download a copy from www.bwsr.state.mn.us 17. DESCRIPTION OF REPLACEMENT WETLANDS: Complete the chart below: I) Use one row of boxes for each wetland replacement site; 2) If your project has more that one wetland replacement site, reference your overhead view (part of Section 5) to this chan by identifying and labeling “first replacement site” and “second replacement site” on your overhead view; 3) If you are identifying only one wetland type within a given replacement site, use the first dotted line(s) and leave the others blank; 4) If you have chosen to identify more than one wetland type in a given replacement site, use the extra dotted lines to indicate each separate wetland type, and identify type(s) of replacement credits and “restored or createdTor each separate wetland type with that replacement site; 5) If you do not have access to some of the information, or if you do not know your replacement ratio, call your LGU or SWCBffice for assistance. Photocopy chart for more wetland replacements, if needed.) DESCRIPTION OF REPLACEMENT WETLANDS Identify Wetland Watershed name or number (if known) County Section, Township, Range WetiandType’Type(s) of repiacement credits (in acres or square feet) Restored orreplacementcreated? Indicate R or C New Wetiand Credits (NWC) Pubiic Vaiue Credits (PVC)site (as noted on overhead view) s/a2^.c.Name of First 56 OHerti9ic /37repiacement site 73 Name of Second replacement site ^Circular 39 wetland types: Indicatel, IL, 2, 3, 4, 5, 6, 7, 8, R, or U. If you are identifying only one wetland type within a given wetland impact area, use the first dotted line and leave the others blank. If you have chosen to identify more than one wetland type within a given wetland impact area, use the extra dotted lines to indicate each separate wetland type, and identify predominant vegetation and size of impacted area for each separate wetland type within that impact area. TOTAL NWC TOTAL PVC REQUIRED REPLACEMENT RATIO: (If known) ^ / Minnesota Local/State/Federal Application Forms for WalerAVetland Projects Page 5 18. ADDITIONAL INFORMATION REQUIRED FOR PROJECT-SPECIFIC REPLACEMENT (Requiredon/i> if you marked Box B or Box C in Section 14): JFor projects involving at least some project-specific replacement, include the following additional information; drawings to scaleof the replacement wetland. Include both overhead view and profile (side view or cross-sectional view). Setf'har w Include on Plans (Instructions, Page 3) for a detailed description of what should be included in these drawings. Without drawingyour application will be considered incomplete. B^or created replacement wetlands, include additional soils information (if available) that indicates the capability of the site to produce and maintain wetland characteristics. Note 1: For replacement wetlands located on pipeline easements,you need to receive endorsement of your project from both the easement holder and the Minnesota Department of Public Safety’s Office of Pipeline Safety. Before start of construction, the owner of any utilities must be nefied. The landowner or contractor is responsible forgiving this notice by calling "Gopher State One-Call” at 652-454-0002 (Twin Cities Metro Area) or l-800-252-14^all other locations). Note 2: For extensive or complex projectssupplementary information may be requested at a later dated from one or more of the responding agencies. Such information may include (but not be limited to) the following: topographic map, water table map, soil borings, depth sodings, aerial photographs, environmental assessment and/or engineering reports. 19. SIGNED AFFIRMATION: FOR PROJECTS INVOLVING REPLACEMENT BY WETLAND BANKING ONLY. To the best of my knowledge and belief, all informatibn in Pan II is true, complete and accurate; and 1 affirm that the wetland losses will be replaced via withdrawal from an account in the State WetiahBank. FOR PROJECTS INVOLVING EITHER PROJECT-SPECIFIC REPLACEMENT ONLY OR A COMBINATION OF WETLAND BANKING AND PROJECT-SPECIFIC REPLACEMENT: Part A: The replacement wetland. I affirm that the replacement wetland was not; Previously restored or created under a prior approved replacement plan or permitAND Drained or filled under an exemption during the previous 10 years; AND Restored with financial assistance from public conservation programsAND Restored using private funds, other than landowner funds, unless the funds are paid back with interest to the individual organization that funded the restoration; and the individual or organization notifies the local government unit in writing that the restored wetland may be considered for replacement. Part B: Additional assurances (check allthat apply); B'The wetland will be replaced before or concurrent with the actual draining or filling of a wetland. O An irrevocable bank letter of credit, performance bond, or other acceptable security has been provided to guarantee successfnbmpletion of the wetland replacement. O The wetland losses will be replaced via withdrawal from an account in the State Wetland Bank. Part C. For projects involving any project-specific replacement: Within 30 days of either receiving approval of this application or beginning work on the project, 1 will record the Declaration of Restrictions and Covenants on the deed for the property on which the replacement wetland(s) wSib located; and I will at the same time submit proof of such recording to the LGU. To the best of my knowledge and belief, all information in Part 11 is true, complete and accurate; and 1 affirm all statements in Part A and C, as well as checked assurance(s) in Part B. Signature or applicant orhgent FOR LGU USE ONLY Replacement plan is (check one): Q Approved DApproved with conditions (conditions attached)Q Denied LGU official signature Date LGU has receive evidence of title and proof of recordingof Declaration of Restrictions and Covenants for Replacement Wetland: County where recorded Document # assigned by recorderDate LGU official signature Date Minnesota Local/State/Federal Application Forms for Water/Wetland Projects Page 6