stateof wisconsin（威斯康辛州的国家）（6页）.docVIP

Notice: This application form template was drafted by the Wisconsin Department of Natural Resources (DNR) and the Wisconsin Department of Agriculture, Trade and Consumer Protection (DATCP). Applications are hereby made to the DNR’s Bureau of Watershed Management and to DATCP’s Bureau of Land and Water Resources for grant assistance consistent with and under the authority of s. 92.14, Wis. Stats., and ch. ATCP?50, Wis. Adm. Code, and the authority of s. 281.65(4e), Wis. Stats., and chs. NR 153 and 154, Wis. Adm. Code. Collection of this information is authorized under the authority of ss. 281.65 and 92.14, Wis. Stats. Personal information collected will be used for administrative purposes and may be provided to requesters to the extent required by Wisconsin’s Open Records Law [ss. 19.31 – 19.39, Wis. Stats.]. Unless otherwise noted, all citations refer to Wisconsin Administrative Code. Caution: Notice of Discharge grants may not be used to cost-share best management practices to address discharges for which the landowner or operator has been referred to the Wisconsin Department of Justice for prosecution. Part 1: Applicant Information Project/Landowner Name ????? Governmental Unit Applying (Name and Type) (Example: Dane County Land Water Resources Department) ????? Name of Responsible Municipal Representative (First Last) ????? Name of Governmental Contact Person (First Last) (if different) ????? Title ????? Title ????? Area Code + Telephone Number ????? Area Code + Telephone Number ????? Area Code + Fax Number ????? Area Code + Fax Number ????? E-Mail Address ????? E-mail Address ????? Mailing Address – Street or Route ????? Mailing Address – Street or Route ????? City, State, Zip Code ????? City, State, Zip Code ????? Part 2: Project Location A. Map and Photograph Submittal Requirement: This application must be accompanied by maps and photographs of the project site. Mapping requirements are: The base map should be an air pho