ࡱ>  bjbjVV <<b SSSSS\M,w6 !("L#PT+V+V+V+V+V+V+E-/zV+S#!!##V+SS ,p%p%p%#:S S T+p%#T+p%p%:),T* <#) @+,0M,*Ra0d$ a0T*a0ST*##p%#####V+V+p%###M,####a0######### : JOINT APPLICATION FORM FOR ILLINOISITEMS 1 AND 2 FOR AGENCY USE1. Application Number2. Date Received3. and 4. (SEE SPECIAL INSTRUCTIONS) NAME, MAILING ADDRESS AND TELEPHONE NUMBERS3a. Applicant s Name  FORMTEXT       Company Name (if any)  FORMTEXT       Address  FORMTEXT       Email Address  FORMTEXT      3b. Co-Applicant/Property Owner Name (if needed or if different from applicant)  FORMTEXT       Company Name (if any)  FORMTEXT       Address  FORMTEXT       Email Address  FORMTEXT      4. Authorized Agent (an agent is not required)  FORMTEXT       Company Name (if any)  FORMTEXT       Address  FORMTEXT       Email Address  FORMTEXT      Applicant s Phone Nos. w/area code Business:  FORMTEXT       Residence:  FORMTEXT       Cell:  FORMTEXT       Fax:  FORMTEXT       Applicant s Phone Nos. w/area code Business:  FORMTEXT       Residence:  FORMTEXT       Cell:  FORMTEXT       Fax:  FORMTEXT      Agent s Phone Nos. w/area code Business:  FORMTEXT       Residence:  FORMTEXT       Cell:  FORMTEXT       Fax:  FORMTEXT      STATEMENT OF AUTHORIZATION I hereby authorize,  FORMTEXT      __________________________________ to act in my behalf as my agent in the processing of this application and to furnish, upon request, supplemental information in support of this permit application. _____________________________________________________ ___________________________________________ Applicants Signature Date5. ADJOINING PROPERTY OWNERS (Upstream and Downstream of the water body and within Visual Reach of Project)Name a. FORMTEXT       b.  FORMTEXT       c.  FORMTEXT       d.  FORMTEXT      Mailing Address  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT      Phone No. w/area code  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT      6. PROJECT TITLE:  FORMTEXT      7. PROJECT LOCATION LATITUDE:  FORMTEXT       LONGITUDE:  FORMTEXT       UTMs Northing:  FORMTEXT       Easting:  FORMTEXT      STREET, ROAD, OR OTHER DESCRIPTIVE LOCATION  FORMTEXT      LEGAL DESCRIPT QUARTER  FORMTEXT      SECTION  FORMTEXT      TOWNSHIP NO.  FORMTEXT      RANGE  FORMTEXT       FORMCHECKBOX  IN OR  FORMCHECKBOX  NEAR CITY OF TOWN (check appropriate box) Municipality Name  FORMTEXT      WATERWAY  FORMTEXT      RIVER MILE (if applicable)  FORMTEXT      COUNTY  FORMTEXT      STATE  FORMTEXT      ZIP CODE  FORMTEXT      Revised 2011  FORMCHECKBOX  Corps of Engineers  FORMCHECKBOX  IL Dept of Natural Resources  FORMCHECKBOX  IL Environmental Protection Agency  FORMCHECKBOX  Applicant s Copy 8. PROJECT DESCRIPTION (Include all features):  FORMTEXT       9. PURPOSE AND NEED OF PROJECT:  FORMTEXT       COMPLETE THE FOLLOWING FOUR BLOCKS IF DREDGED AND/OR FILL MATERIAL IS TO BE DISCHARGED10. REASON(S) FOR DISCHARGE:  FORMTEXT       11. TYPE(S) OF MATERIAL BEING DISCHARGED AND THE AMOUNT OF EACH TYPE IN CUBIC YARDS FOR WATERWAYS: TYPE:  FORMTEXT       AMOUNT IN CUBIC YARDS:  FORMTEXT       12. SURFACE AREA IN ACRES OF WETLANDS OR OTHER WATERS FILLED (See Instructions)  FORMTEXT      13. 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List all approvals or certification and denials received from other Federal, interstate, state, or local agencies for structures, construction, discharges or other activities described in this application.Issuing AgencyType of ApprovalIdentification No.Date of ApplicationDate of ApprovalDate of Denial FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      17. CONSENT TO ENTER PROPERTY LISTED IN PART 7 ABOVE IS HEREBY GRANTED.Yes FORMTEXT    No FORMTEXT    18. APPLICATION VERIFICATION (SEE SPECIAL INSTRUCTIONS)Application is hereby made for the activities described herein. I certify that I am familiar with the information contained in the application, and that to the best of my knowledge and belief, such information is true, complete, and accurate. I further certify that I possess the authority to undertake the proposed activities. 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