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<br />10. D.nr ;¢trvity is prnposeA to coAmenc~ Januar <br />D:ite octl vi ry is ewpected to be completed 6~ ~d YS from SCdrt <br />11. Is any uonion of the arhvny /or whltr authorization is wu9h1 now compl ete~ ~ YES a NO <br />II answer is "Yes" give reasons m the remark section. Month and year the activity was rompletrd <br />Indr cat¢ the earsb ng work un the drawings. <br />_-J <br />r:. 1151 .JI nl~pm va'\ M pr•'bhrnlrOnS rP.yw reA by OlhPi IPder.d, UJ Pr Sr al r, SIaY ui Inl::d .ini~nrr r:. Im ,urv Sinn Iu1r. rr.•.ul-- <br />hui`, 4151 lyliilP S, dPpo:als or Other ALliyiliPS dP Si'n hr`d 11 IL15 .rppllcallpn, <br />~ I54(u nl AI .•iiry T P A un vat Idennhcab on Nn. Dale al A >Ilc:dion U.iir ,d A . ~r(.v.il <br />I i i yr PI of 11 __ <br />13. Has any agency denied approval fur the ncti vity descn bed herein or br any acb vrty drte[tly related to thr ac^vl ly <br />dPSCnbed herein <br />^ yes ® No 111 "Yes" enpl aiii iii rem ark ll <br />14. Remarks or additional information. <br />I5. App1l r.:nipu r5 hrreby made for n prrmrl or permits In .oJhorl[¢ the acli vib¢s de SCn bnd herein. 1 I: artily ihdt I a1n LumlLu <br />write Ihtl rnlonn atinn COnta mad In This applmallun, :Mid Ihnl 111 the ball OI mY MnowlCdge end b¢IiBf ShCh nd.rtni.dlnn r•. Un•~ <br />CUrnlll l•I rv, .rrld .II: L'llr al ¢. I Ilrl nl ¢r 1:¢1111y Thal 111115 \r•5\ Ir1C rr(I II Ir IIrly 1(I IIn1f1!r1 i111e IhP prnP05r•d IICII Vr IrP!., <br />] / , <br />Signature of Applicant or udlonzed 4geni <br />The eyplieatiori must be signed by the applicant; however, i1 may be signed tilr a duly eathori zed agent lnemed in Item 5) <br />it dlis form i5 accompanied by a statBmnnt b1' Me applicant designating the agent end agreeing to IumiSh upon regiie 5t, <br />siipplementnl information in support of the application. <br />~ 18 U. 5. C. Section 1001 provides that: NToaver, in any mavter within the furl sdi etitin of any dapartrnent or agency <br />of The United States knowingly end willfully lal silies, conceals, or covers up by any Iii Ck, stdieme, or device a material tact <br />ur makes any false. hctlhous pr Iraudu lent statements or representations or makes or uses any lal se writing or Ifocumenf <br />knowing sane to contain any lal se fict rtrous or fraudulent st element or entry, shall ba linod not more than 510.000 or <br />imprl si oned not mere than live years. or both. Do not smd a pmmit processing fee with this application. The anpropri ate <br />lee will be assessed when a permit is issued. <br />