Water Resource Permit Application - Combined Joint Notification Form Page 2
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1
2INSTRUCTIONS – PLEASE READ CAREFULLY
A copy of this form, with copies of all plans, drawings, etc… may need to be sent to an agency indicated below... Please check
the appropriate spaces below to show everywhere you are sending this form. Remember to keep a copy for your records.
____ MINNESOTA POLLUTION CONTROL AGENCY (MPCA) for NPDES phase II permit
____ The LOCAL GOVERNMENTAL UNIT (LGU), city, county or water management organization
____ MINNESOTA DEPARTMENT OF NATURAL RESOURCES (MDNR) Regional Office
____ US ARMY CORPS OF ENGINEERS (ACOE) at Dept. of the Army, Corps of Engineers, St. Paul District
ATTN: CO-R, 190 Fifth St. East, St. Paul, MN 55101-1638
Note: The above Agencies may provide a copy of your completed form to the Minnesota Pollution Control Agency (MPCA).
MPCA water quality requirements may apply to your proposed project.
ATTENTION (from USDA): Any activity including drainage, dredging, filling, leveling or other manipulations, including
maintenance, may affect a land user’s eligibility for USDA benefits under the 1985 Food Security Act as amended. Check with
your local USDA office to request and complete Form AD-1026 prior to initiating activity.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Application is hereby made for a permit to authorize the activities described herein. I certify that I am familiar with MCWD
Rules and that the proposed activity will be conducted in compliance with these Rules. I am familiar with the information
contained in this application and, to the best of my knowledge and belief, all information is true, complete and accurate. I
further certify that I possess the authority to undertake the proposed activity or I am acting as the duly authorized agent of the
applicant.
_________________________________
____________
_________________________________ _____________
Signature of Applicant (Property Owner)
Date
Signature of Agent
Date
NOTE: The application must be signed by the property owner where the proposed activity is to occur. The application may be
signed by a duly authorized agent if a letter bearing the original signature of the property owner is submitted stating that the
agent noted in the permit application is the authorized agent of the landowner for all matters relating to the permit. Please
provide authorized agent information
below:
Agent’s Name & Title: _______________________________________________________________
Agent’s Address: ___________________________________________________________________
Agent’s Telephone: (_____) _____________________
18 U.S.C. Section 1001 provides that: Whoever, in any manner within jurisdiction of any department or agency of the United
States knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact or makes any
false, fictitious or fraudulent statements or representations or makes or uses any false writing document knowing same to
contain any false, fictitious, or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than
five years, or both.
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