07/15/2004 Env Bd Packet - Laserfiche WebLink

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[]26202 1 PART 1: BASIC APPLICATION "See HELP' directs you to important additional information and assistance in Instructions, page 1. 1-11. APPLICANT CONTACT INFORMATION (See HELP 11: • t i Name: Ed Vauahan Complete mailing address: 1 1432 Pheasant Hills Drive 1 1 0 Lino Lakes, MN 55038 1 Residential phone: (651 ) 490 -0459 Business phone: ( ) tFax (if available): (651 ) 426 -5053 email (if available): • 1. PROJECT NAME OR TITLE (if applicable): Pheasant Hills Island 113. NAME OR I.D. # OF WATER BODY/BODIES IMPACTED* (if applicable; if known): 1OP (Wards Lake) 4a. ANY WETLANDS IMPACTED? (check one) NO 4b. If YES, what type (if known; check all that apply): 11 4 e !unknown 1 1A. AUTHORIZED AGENT (See HELP 1A.1 (only if applicable; an agent is not requi)d) Name: Ron Peterson Title: Peterson Envtl. Consulting Mailing address: 1355 Mendota Hts. Rd, Suite 100 Mendota Heights, MN 55120 Residential phone: ( ) Business phone: (651 ) 905 -6123 Fax (if available): ( 651 ) 686 -0369 email (if available): rpeterson @petesonenv.com I hereby authorize Ronald P. Peterson to act in my behalf as an age . in the processing of this • .. 'cation and to fu . 4, upon request, supple - , 6 t ,, ' in su • . rt of this application. e S - /,oy Applicant si: natur: Date 4c. If YES, indicate size of entire wetland (check one): O Less than 10 acres (indicate size: ) D 10 to 40 acres 0 Greater than 40 acres 5. PROJECT LOCATION ** (information can be found on property tax statement, property title or title insurance 1/4 section: NW:NE Section: 27:28 Township: 31 N Range: 22W County: Anoka Lot #: Block: Subdivision: 6. ADDITIONAL LOCATION DESCRIPTIONS ** (if applicable; if known): Parcel ID # /Geocode• M coordinates: easterly 493,495 northerly 4,999,618 = roject street address: Fire #• For multiple water bodies or locations, attach additional sheets labeled ADDITIONAL WATER BODIES IMPACTED, ADDITIONAL PROJECT LOCATIONS, or ADDITIONAL LOCATION DESCRIPTIONS.