Iowa Department of Natural Resources Class I Dock Permit Application

 Class I DO NOT USE – FOR OFFICIAL USE ONLY Dock Permit No.______By checking the above box, I certify that Date Issued______Expires______this dock meets the criteria for a Class I ______permit. A Class I dock permit shall be Officer valid only while dock and hoists comply ______with the criteria for a Class I permit. District Supervisor

I am applying for: (check appropriate box)

 Renewal of existing permit – Give permit number:______ New permit  Change of existing permit – Give permit number and name of present permittee: ______

Print legibly:

A. Length of dock from water’s edge to end of dock including F. Number of hoists/slips: ______width of “L” or “T”: ______ft. G. Each dock, hoist, moored vessel and other permitted B. Length of dock from water’s edge to where water reaches structure shall be offset a minimum of 5 feet from an 3 feet in depth: ______ft. adjoining property line and 5 feet from the projection of a line perpendicular from the shoreline at the common C. Width of main dock: ______ft. boundary with adjoining shoreline property.

D. Dimensions of “L” or “T” portion: (length): ______ft. The shortest distance from any dock, hoist, moored vessel by (width): ______ft. or other permitted structure to adjoining property line. Left: ______ft. Right: ______ft E. Width of lakeshore property at ordinary high water mark: ______ft.

- Continued on back page -

1 – 4/9/2007 If this application is for a shared or common dock, provide both names and addresses

Applicant’s Name

______(Last) (First) (Initial)

Applicant’s Permanent Mailing Address:

______(Street or Box #) (City, State & Zip Code)

Applicant’s Phone Number(s) and E-mail Address(es):

______(Phone Number) (E-mail Address - optional)

911 Address assigned to the property served by the dock

______(Street) (City, State & Zip Code)

Name and signature of riparian property owner if other than applicant:

______(Print Name) (Signature)

Name of lake or river:______Incomplete or illegible applications will be returned.

I understand that providing false information automatically makes this dock application invalid and could result in penalties for making a false entry in a public record under Iowa Code 714.8(4).

______Name Date

Please send completed application to the appropriate Regional Office where dock is located. Addresses are listed below.

NW Regional Office SE Regional Office Spirit Lake Fish Hatchery Lake Darling State Park 122 - 252nd Avenue, Spirit Lake, IA 51360 110 Lake Darling Road, Brighton, IA 52540 Phone number: (712) 336-1840 Phone number: (319) 694-2430

NE Regional Office NC Regional Office Manchester Fish Hatchery 1203 N. Shore Drive, Clear Lake, IA 50428 22693 - 205th Avenue, Manchester, IA 52057 Phone number: (641) 357-3517 Phone number: (563) 927-3276

SW Regional Office SC Regional Office Cold Springs State Park Wallace State Office Building

2 – 4/9/2007 57744 Lewis Rd, Lewis, IA 51544 502 E. 9th Street, Des Moines, IA 50319 Phone number: (712) 769-2587 Phone number: (515) 281-8174

3 – 4/9/2007