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the completed a, plication forms, the following items must bt . .ovided. work plat drawn to scale on 8? x 10%?? white papor (see instruction booklet for details), pfiate written report or statement of the environmental impact of the proposed activity.
.ication is hereby made for a permit or permits to authorize the activities described herein. I agree to provide any Jitional information/data that may be necessary to provide reasonable assurance or evidence to show that the proposed voject will comply with the applicable State Water Quality Standards or other environmental protection standards both during construction and after the project is completed. I also agree to provide entry to the project site for inspectors from the environmental protection agencies for the purpose of making preliminary analyses of the site and monitoring permitted works. If permit is granted. I certify that I am familiar with the information contained in this 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.
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Signature of Applicant
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' Date
1 8 U.SC. Section 1 001 provides that: Whoever, in any manner within the jurisdiction of any deportment or agency of the United States knowingly and willingfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact or makes any false, fictitious or fraudulent statements or representations or makes or uses any false writing or document knowing same to contain any false fictitious or fraudulent statement or entry, shall be fined not more than $1 0.000 or imprisioned not more than five years, or both.
The application must be signed by the person who desires to undertake the proposed activity; however, the application may be signed by a duly authorized agent if accompanied by a statement by that person designating the agent and agreeing to furnish upon request,	?
supplemental information in support of the application.
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18.	Fees:
Payable to State of Mississippi S10 Application Fee
$35 Cost of Publications of Public Notice
Payable to Treasurer of the United States $1 00 Commercial $10 Non-Commercial
State of Mississippi Fee to be included with application to the	?
Bureau of Marine Resources.
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Do not submit with application.
Fee acceptable only at time of issuance of permit.
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19.	Send one completed copy, to each of the agencies listed below.
District Engineer
U. S. Army Engineer District, Mobile Attn: SAMOP-S P. O. Box 2288 Mobile, Alabama 36628
Bureau Director
Bureau of Marine Resources
P. O. Drawer 959
Long Beach, Mississippi 39560
Bureau Director
Bureau of Pollution Control
P. O. Box 827
Jackson, Mississippi 39205