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B u s i n e s s : F O R M T E X T
R e s i d e n c e : F O R M T E X T
C e l l : F O R M T E X T
F a x : F O R M T E X T A p p l i c a n t s P h o n e N o s . w / a r e a c o d e
B u s i n e s s : F O R M T E X T
R e s i d e n c e : F O R M T E X T
C e l l : F O R M T E X T
F a x : F O R M T E X T A g e n t s P h o n e N o s . w / a r e a c o d e
B u s i n e s s : F O R M T E X T
R e s i d e n c e : F O R M T E X T
C e l l : F O R M T E X T
F a x : F O R M T E X T S T A T E M E N T O F A U T H O R I Z A T I O N
I h e r e b y a u t h o r i z e , F O R M T E X T _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ t o a c t i n m y b e h a l f a s 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)Name
1. FORMTEXT
2 . F O R M T E X T
3 . F O R M T E X T
4 . F O R M T E X T M a i l i n g A d d r e s s
F O R M T E X T
F O R M T E X T
F O R M T E X T
F O R M T E X T P h o n e N o . w / a r e a c o d e
F O R M T E X T
F O R M T E X T
F O R M T E X T
F O R M T E X T 6 . P R O J E C T T I T L E :
F O R M T E X T 7 . P R O J E C T D E S C R I P T I O N ( I n c l u d e a l l f e a t u r e s ) : F O R M T E X T
8 . P U R P O S E A N D N E E D O F P R O J E C T : F O R M T E X T
S u b m i s s i o n o f t h e a p p r o p r i a t e f o r m ( s ) i s r e q u i r e d b y t h e I o w a D e p a r t m e nt of Natural Resources Flood Plain Management Program (also known in this form as the Flood Plain Permits Section). The forms for various project types can be obtained online within HYPERLINK "http://floodplain.iowadnr.gov/" http://floodplain.iowadnr.gov/ or by calling 866/849-0321.
COMPLETE THE FOLLOWING FOUR BLOCKS IF DREDGED AND/OR FILL MATERIAL IS TO BE DISCHARGED9. REASON(S) FOR DISCHARGE: FORMTEXT
1 0 . T Y P E ( S ) O F M A T E R I A L B E I N G D I S C H A R G E D A N D T H E A M O U N T O F E A C H T Y P E I N C U B I C Y A R D S :
T Y P E : F O R M T E X T
A M O U N T I N C U B I C Y A R D S : F O R M T E X T
1 1 . S U R F A C E A R E A I N A C R E S O F W E T L A N D S O R O T H E R W A T E R S F I L L E D , A N D S T R E A M L E N G T H I F A P P L I C A B L E ( S e e I n s t r u c t i o n s )
F O R M T E X T 1 2 . D E S C R I P T I O N O F A V O I D A N C E , M I N I M I Z A T I O N A N D C O M P E N S A T I O N ( S e e i n s t r u c t i o n s )
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