Lake
Lemon Shoreline Project Permit Request
1. Name and Address of Applicant: Name and Address of Contractor or Agent
_______________________ ________________________
_______________________ ________________________
_______________________ ________________________
Home Phone: ______________ Home
Phone: ______________
Office Phone: ______________ Office
Phone: ______________
2.
Detailed Description of Proposed Project (attach drawings, dimensions,
blueprint – if available, and photographs)
3.
Purpose of Proposed Project
4.
Dredged or Fill Material (source and total cubic yards to be placed where)
5.
Other Materials to be Used on this Project
6.
Names and Addresses of Adjoining Property Owners or Lessees whose property also
adjoins the lake.
______________________________ ________________________________
______________________________ ________________________________
______________________________ ________________________________
______________________________ ________________________________
7.
Location on land where project is proposed
Address
________________________________________________
City ___________________________, IN County
_________________ Zip _________
Near what lake landmarks (i.e., spillway,
dam, Schell Marina, Riddle Point, causeway, etc.)
8.
List all approvals or certifications and denials received from Federal, State,
or Local Agencies for any construction, structures, discharges or other
activities described in this application.
Agency Type Approval ID No.
Approval Date
Denial Date
______________
______________ ______________
______________ ______________
______________
______________ ______________
______________ ______________
______________
______________ ______________
______________ ______________
______________
______________ ______________
______________ ______________
______________
______________ ______________
______________ ______________
______________
______________ ______________
______________
______________
9. Application is hereby made for a permit to authorize the project activities described herein. I certify that I am familiar with the information contained in this application, and to the best of my knowledge and belief, such knowledge is true, complete and accurate. I further certify that I possess the authority to undertake the proposed activities or I am acting as the duly authorized agent of the applicant.
_________________________ ____________ _______________________
___________
(Signature
of Applicant) (Date) (Signature of Contractor or Agent) (Date)
The application must be signed by the person who desires to undertake the proposed project (applicant) and also must be signed by the contractor or agent if one is involved.
Return
completed application to: Lake Lemon Conservancy District
Unionville,
IN 47468
Phone:
812-334-0233