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TION FOR DEPARTMENT OF THE ARMY PERMIT <br />(33 CFR 325) OMB APPROVAL NO. 0710-003 <br />' lic reporting burden for [his collection of infortna[ion is estimated to average 5 hours per response, including the time for reviewing instructions. <br />catching existing data sources, gathering and maintaining the tlata neetletl, and completing and reviewing [he colection of infonna[IOn. Send <br />comments regarding this Durden estimate or any other aspect of this collection of in/arma[ion, including suggestions for reducing this burden, to <br />Department of Defense. Washington Headquarters Service Directorate of Information Operations and Reports. 1215 Jefferson Davis Highway. Suite <br />7204, Arlington VA 22202.4302; end to the Office of Management and Budget, Paperwork Reduction Project (0710-003), Washington, DC 20503. <br />Please DO NOT RETURN your form to either of those atldresses. Completed applications must be submitted to [he District Engineer having jurisdiction <br />over the location of the proposed activity. <br />PR{VACY ACT STATEMENT <br />Authority: 33 USC 401, Section 10; 1413, $ectian 404. Principal Purpose: These laws require permits authorizing activKies in, or affecting, navigable <br />waters of the Unrted States; the discharge of dredged or fill material Into waters of the United States, and the Vanspatatbn of dredged material for the <br />purpose of dumping it Into ocean waters. Routine uses: Information provided on this form will be used in evaluating the application for a permit. <br />Disdawre: Oiscbsure of requested irtfamtation is voluntary. It information is not provides, however, the pettnit application cannot be processed nor <br />can a permit be issued. <br />One set of original drawings or good reproducible copies which show the location and character of the proposetl activity must be attached to this <br />application (see sample drawings and instructions) and be submitted to the District Engineer havingjuristlic[IOn over [he proposed activity. An <br />(ITEMS 1 THRU 4 TO BE FILLED BY THE CORPS) <br />1. APPLICATION NO. 2. FIELD OFFICE CODE 3. DATE RECEIVED 4. DATE APPLICATION COMPLETED <br />(ITEMS BELOW TO BE FILLED BY APPLICANT) <br />5. APPLICANT'S NAME 6. AUTHORIZED AGENT'S NAME & TITLE (an agent is not required) <br />3 3 c ivTt/'2P RZ Sc S , ~..L.c. S ~ t-vE 6Ak"YL M ,g N A C'I CAL. <br />6. APPLICANT'S ADDRESS g. AGENT'S ADDRESS <br />t'Ztoo c . S ~'-T S' iYZCC T'I C2~l.LC1 c0 {~. C ~ c ~ (~v lG ~ ~-t~•a~C-~ ~ C O <br /> y Ito zcp <br />7. APPLICANT'S PHONE NUMBERS WITH AREA CODE 10. AGENT'S PHONE NUMBERS WITH AREA CODE <br />a. Residence a. Residence <br />b. Business ct-1 0 ~ 8 zQ• - c 2_2r b. Business `j -(C - 3 Z(o - ~ 3 SIP ~ccZl_ <br />11. STATEMENT OF AUTHORIZATION <br />I hereby authorize SZ~~ t= ~~)~ LIZ to act in my behalf as my agent in the processing of this <br />application and to furnish, u`~O <br />sup <br />pl <br />, coral information in support of [his permit application. <br />n' request <br />/~ <br />~ <br />~ <br />t <br />, <br />\ <br />`~1 a~ 1 J( 1 s ~' c <br />APPLICANT' ATURE ATE <br />NAME, LOCATION, AND DESCRIPTION OF PROJECT OR ACTIVITY <br />12. PROJECT NAME OR TITLE (see instructions) <br /> ~B CN~r~-12 ~2-+-Si=S - l7 c"~VC -/,f~S ~r t <br />13. NAME OF WATERBODY, IF KNOWN (if applicable) 14. PROJECT STREET ADDRESS (if applicable) <br /> N~~ ,zcc c. ter s~zc~ ~ <br />15. LOCATION OF PROJECT C2 ~+ C--i \ <br />Crz-,A.~ C~ I Cv <br /> r1 ,( <br />COUNTY I t'`~ ~ F'~ ( STATE C CJ <br />16. OTHER LOCATION DESCRIPTION <br />S, <br />IF KNOWN (see instruc[:ons) <br /> s <br />/ <br />N /r'T <br />7 7. DIRECTIONS TO THE SITE <br /> ~ t_c ass E' S <"~ c-7~7 ~ Lc S C r] c/.=C .i=-n.l _i "~/ /H ~~„ <br />