20150565 Ver 1_Signature Page_20150616

5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.):
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
9. Will work be conducted from land? From water?
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the normal pool lake level/ Normal Water Level in square feet or acres:
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool lake level/ Normal Water Level and 50 feet land -ward
in square feet or acres:
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and
50 feet landward to be impacted (number of trees, for instance):
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Owner /Agent's Signature* [ Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10 -2013 Page 3 of 3