<p> DEPARTMENT OF THE ARMY ROCK ISLAND DISTRICT, CORPS OF ENGINEERS CLOCK TOWER BUILDING - P.O. BOX 2004 ROCK ISLAND, ILLINOIS 61204-2004</p><p>Operations Division </p><p>Please complete and return the enclosed Boat Dock Application packet so we may begin processing of the Department of the Army (DA) permit that is required for your dock(s). This packet contains the necessary application form, attachment, and drawings sheets. </p><p>Please fill out these sheets completely and include a good location map so we may have enough information to process your application. </p><p>The copy of the completed application form and drawing sheets marked and any other pertinent information should be mailed to: </p><p>U.S. Army Corps of Engineers, Rock Island ATTN: CEMVR-OD-P Clock Tower Building Post Office Box 2004 Rock Island, Illinois 61204-2004 </p><p>Under an agreement with the State of Iowa, any boat dock application on the Mississippi River shall be processed by the Corps of Engineers. A copy of any decision made by our office will be provided to the Iowa Department of Natural Resources. </p><p>Should you have any questions, please contact our Regulatory Branch by letter, or telephone Ms. Sue Apple, 309/794-5376. JOINT APPLICATION FORM FOR IOWA ITEMS 1 AND 2 FOR AGENCY USE 1. Application Number 2. Date Received</p><p>3. and 4. (SEE SPECIAL INSTRUCTIONS) NAME, MAILING ADDRESS AND TELEPHONE NUMBERS 3a. Applicant’s Name 3b. Co-Applicant/Property Owner Name 4. Authorized Agent (an agent is not required) (if needed or if different from applicant) Company Name (if any) Company Name (if any) Company Name (if any) Address Address Address City, State, Zip City, State, Zip City, State, Zip Email Address Email Address Email Address </p><p>Applicant’s Phone Nos. w/area code Applicant’s Phone Nos. w/area code Agent’s Phone Nos. w/area code Business: Business: Business: Residence: Residence: Residence: Cell: Cell: Cell: Fax: Fax: Fax: STATEMENT OF AUTHORIZATION I hereby authorize, to act in my behalf as my agent in the processing of this application and to furnish, upon request, supplemental information in support of this permit application.</p><p>Applicant’s Signature Date 5. ADJOINING PROPERTY OWNERS (Upstream and Downstream of the water body) Name Mailing Address Phone No. w/area code 1. </p><p>2. </p><p>3. 6. PROJECT TITLE:</p><p>7. PROJECT DESCRIPTION (Include all features): </p><p>8. PURPOSE AND NEED OF PROJECT: Submission of the appropriate form(s) is required by the Iowa Department of Natural Resources Flood Plain Management Program (also known in this form as the Flood Plain Permits Section). The forms for various project types can be obtained online within http://floodplain.iowadnr.gov/ or by calling 866/849-0321.</p><p>COMPLETE THE FOLLOWING FOUR BLOCKS IF DREDGED AND/OR FILL MATERIAL IS TO BE DISCHARGED 9. REASON(S) FOR DISCHARGE: </p><p>10. TYPE(S) OF MATERIAL BEING DISCHARGED AND THE AMOUNT OF EACH TYPE IN CUBIC YARDS: TYPE: </p><p>AMOUNT IN CUBIC YARDS: 11. SURFACE AREA IN ACRES OF WETLANDS OR OTHER WATERS FILLED, AND STREAM LENGTH IF APPLICABLE (See Instructions)</p><p>12. DESCRIPTION OF AVOIDANCE, MINIMIZATION AND COMPENSATION (See instructions)</p><p>13. PROJECT LOCATION GIS Coordinates in NAD 1983 UTM Zone 15 LATITUDE: Northing: </p><p>LONGITUDE: Easting: STREET, ROAD, OR OTHER DESCRIPTIVE LOCATION LEGAL QUARTER SECTION TOWNSHIP NO. RANGE DESCR</p><p>IN OR NEAR CITY OR TOWN (check appropriate box) WATERWAY RIVER MILE (if applicable) Municipality Name COUNTY STATE ZIP CODE</p><p>14. Date activity is proposed to commence Date activity is expected to be completed 15. Is any portion of the activity for which authorization is sought now complete? Yes No NOTE: If answer is “YES” give reasons in the Project Description and Remarks section.</p><p>Month and Year the activity was completed Indicate the existing work on drawings.</p><p>16. List all approvals or certification and denials received from other Federal, interstate, state, or local agencies for structures, construction, discharges or other activities described in this application. Identification No. Issuing Agency Type of Approval Date of Application Date of Approval Date of Denial</p><p>17. CONSENT TO ENTER PROPERTY LISTED IN PART 13 ABOVE IS HEREBY GRANTED. Yes No 18. APPLICATION VERIFICATION (SEE SPECIAL INSTRUCTIONS) Application is hereby made for the activities described herein. I certify that I am familiar with the information contained in the application, and that to the best of my knowledge and belief, such information is true, complete, and accurate. I further certify that I possess the authority to undertake the proposed activities.</p><p>Signature of Applicant or Authorized Agent Date</p><p>Signature of Applicant or Authorized Agent Date</p><p>Signature of Applicant or Authorized Agent Date Corps of Engineers Iowa Dept of Natural Iowa Dept of Natural Applicant’s Copy Revised 2011 Resources Resources ATTN: Floodplain Permits ATTN: Sovereign Lands Section SEE INSTRUCTIONS FOR ADDRESS LOCATION MAP</p><p>Corps of Engineers Iowa Dept of Natural Resources Revised 2011 ATTN: Floodplain Permits Section Iowa Dept of Natural Applicant’s Copy Resources ATTN: Sovereign Lands PLAN VIEW</p><p>FOR AGENCY USE ONLY</p><p>Corps of Engineers Iowa Dept of Natural Resources Revised 2011 ATTN: Floodplain Permits Section Iowa Dept of Natural Resources Applicant’s Copy ATTN: Sovereign Lands BOAT DOCK APPLICATION ATTACHMENT</p><p>If the riparian riverfront is privately owned, are you the OWNER or LESSEE If you are a lessee, please provide the name and mailing address of the property owner:</p><p>Is the riparian riverfront Government land? YES NO Is this a new dock? YES NO Prior Federal Permits? Is the dock already built and in place? YES NO If YES, when was dock built? Was it constructed by a previous owner? YES NO NAME (if known): (NOTE: If a dock was there when you obtained the property, there may already be a transferable permit existing for the dock. You may wish to check on this first.) DOCK LOCATION: a. City (in or near) b. Section , Township N, Range E W c. County, State d. River, Mile e. Proximity of other structures (i.e. wing dams, pipeline crossings)</p><p>DIMENSIONS: feet long by feet wide Basic shape: L T U Straight Other MATERIALS: Deck surface (wood, metal, plastic, etc.) Frame structure (wood, metal, plastic, etc.) Flotation: Premanufactured Sealed Plastic Floats Barrels Foam Other METHOD OF ANCHORING: Posts/pipes driven into river bottom Cables attached to shore Anchors (i.e., concrete blocks) on river bottom Seawall Any Associated Work: Seawall Boat Rail Riprap Boat Lift Boat ramp Other COMPLETE Mailing Addresses of Adjacent Landowners</p>