Agenda - Environmental Policy Board - 08/21/2023

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Project Name and/or Number: PART ONE: Applicant Information If applicant is an entity(company,government entity, partnership,etc.),an authorized contact person must be identified. If the applicant is using an agent(consultant, lawyer,or other third party)and has authorized them to act on their behalf,the agent's contact information must also be provided. Applicant/Landowner Name: Mailing Address: Phone: E-mail Address: Authorized Contact(do not complete if same as above): Mailing Address: Phone: E-mail Address: Agent Name: Mailing Address: Phone: E-mail Address: PART TWO: Site Location Information County: City/Township: Parcel ID and/or Address: Legal Description (Section,Township, Range): Lat/Long(decimal degrees): Attach a map showing the location of the site in relation to local streets,roads, highways. Approximate size of site(acres)or if a linear project,length(feet): If you know that your proposal will require an individual Permit from the U.S.Army Corps of Engineers,you must provide the names and addresses of all property owners adjacent to the project site. This information may be provided by attaching a list to your application or by using block 25 of the Application for Department of the Army permit which can be obtained at: http://www.mvp.usace.army.mil/Portals/57/docs/regulatory/RegulatoryDocs/engform 4345 2012oct.pdf PART THREE: General Projeect/Site Information If this application is related to a delineation approval,exemption determination,jurisdictional determination, or other correspondence submitted prior to this application then describe that here and provide the Corps of Engineers project number. Describe the project that is being proposed,the project purpose and need,and schedule for implementation and completion.The project description must fully describe the nature and scope of the proposed activity including a description of all project elements that effect aquatic resources(wetland, lake,tributary,etc.)and must also include plans and cross section or profile drawings showing the location, character,and dimensions of all proposed activities and aquatic resource impacts. Minnesota Interagency Water Resource Application Form February 2014 Page 3 of 11