3500 053 Form – Fill Out and Use This PDF

	State of Wisconsin	Water Resources Application for Project Permits
	Department of Natural Resources	Form 3500-053 (R 2/12)	Page 1 of 2
	dnr.wi.gov

Notice: Pursuant to chs. 30 and 31, 281 and s. 283.33, Wis. Stats., this form is used to apply for coverage under the state construction site storm water runoff general permit, and to apply for a state or federal permit or certification for waterway and wetland projects or dam projects. This form and any required attachments constitute the permit application. Failure to complete and submit this application form may result in a fine and/or imprisonment or forfeiture under the provisions of applicable laws including s. 283.91, Wis. Stats. Personal information collected will be used for administrative purposes and may be provided to requesters to the extent required by Wisconsin's Public Records Laws (ss. 19.31-19.39, Wis. Stats.).

Use this form for (check all that apply):

Work in public waters (DNR – ch. 30, Wis. Stats.)	Storm water NOI – New land disturbing construction activity
Work in waters of the U.S (Corps of Engineers)	Storm water NOI – Renewal	FIN #
Permit for Wetland Fill (DNR or Corps of Engineers)	Dam projects (DNR or Corps of Engineers)

Read all instructions provided before completing. If additional space is needed, attach additional pages.

Section 1: Applicant/Permittee Information

Applicant Name (Ind., Org. or Entity)	Authorized Representative	Title
Mailing Address	City	State	ZIP Code
E-mail address	Phone Number (incl. area code)	Fax Number (incl. area code)

Section 2: Landowner Information (complete these fields when project site owner is different than Applicant.)

Name (Organization or Entity)	Contact Person	Title
Mailing Address	City	State	ZIP Code
E-mail address	Phone Number (incl. area code)	Fax Number (incl. area code)

Section 3: Other Contact Information (check one):

Consultant or Plan Preparer	Contractor		Agent	Other	If Other, specify:
Name (Organization or Entity)		Contact Person				Title
Mailing Address		City				State	ZIP Code
E-mail address			Phone Number (incl. area code)			Fax Number	(incl. area code)

Section 4: Project or Site Location

Section 5: Location Information

Create a map depicting the project location or the perimeter of the construction site (land disturbance) and relationship to nearby water resources using the Surface Water Data Viewer http://dnr.wi.gov/org/water/data_viewer.htm or a 7.5-minute series topographic map. You can print the map and then draw the location on the map.

Provide the section, range, township information and if available, the Latitude and Longitude information.

					PLSS (Public Land Survey System) Method
Quarter-Quarter		Quarter			Section	Township	Range	Direction	If this site is not wholly contained
NW	NE	NW		NE		N		E	on the quarter-quarter section,
								W	more description:
SW	SE	SW		SE

Water Resources Project Permits Application

	Form 3500-053 (R 2/12)		Page 2 of 2
Applicant/Project Name:		County:

Section 6: Waterways and Wetlands (see Instructions about potential additional application requirements)

Name (description if unnamed) of closest waterbodies				Type				Special status
					Lake	Stream		ORW/ERW	303(d) listed
Yes	No		Wetlands:
			Wetlands will be filled, excavated, or disturbed during construction or as part of this project.
	The presence of wetlands has been evaluated using: (check all that apply)
			Wisconsin Wetlands Inventory		Wetland Delineation (attach report)
			Wetland Locator Tool		Soils (NRCS maps)			Other (specify)
			http://dnr.wi.gov/wetlands/locating.html

Section 7: Project Information (Attach additional sheets as necessary)

Photos: Provide photographs of the "before" condition.

Date of Photographs:

Narrative of the Project:

Provide a one to two paragraph description of the proposed project, including land and water alterations and intended use(s) of the project.

Section 8: Attachments and Permit Access (Include required attachments for each proposed activity.)

The following attachments, such as the Construction Erosion and Sediment Control (form 3500-052A) and the Post- Construction Storm Water Management (form 3500-052B) for a storm water construction permit application, constitute this permit application: (include all that apply)

Attachment Name(s)

I have obtained a copy of the construction site storm water runoff general permit from the department's Internet site.

http://dnr.wi.gov/runoff/pdf/stormwater/permits/construction/construction_permit_S067831-4.pdf

Section 9: Certification & Permission

Certification: I hereby certify that I am the owner or authorized representative of the owner of the property which is the subject of this Permit Application. I certify that the information contained in this form and attachments is true and accurate. I certify that the project will be in compliance with all permit conditions. I understand that failure to comply with any or all of the provisions of the permit may result in permit revocation and a fine and/or imprisonment or forfeiture under the provisions of applicable laws.

Permission: I hereby give the Department permission to enter and inspect the property at reasonable times, to evaluate this notice and application, and to determine compliance with any resulting permit coverage.

Name of Owner/Authorized Representative (Print or Type)

Title

Phone Number (incl. area code)