Free 15831.xls - Indiana

APPLICATION FOR RECREATIONAL STRUCTURES ON PUBLIC WATERS Pursuant to IC 14-15-7-3 and 312 IAC 5-4
State form 15831 (R8 / 9-05) INSTRUCTIONS: Application must be delivered no later than 60 days prior to the installation of the proposed structure to:

Please print clearly, illegible applications will be returned for correction.
Name of Applicant Address (number and street) (city, state, ZIP code) Name of Organization

Department of Natural Resources Law Enforcement Division Indiana Government Center South 402 W. Washington St. Rm. W-255D Indianapolis, IN 46204 Telephone: (317) 232-4010

Telephone number (Include area code)

Request permission to install the following water recreation structure on the public waters of the State of Indiana: Informational Buoy(s) Navigational Marker(s) Ski Jump Swimming / Diving Platform

Other (Describe) ______________________________________________________________________________________

The structure(s) will be installed on the public waters of ________________________________________________________________
Describe name in full

Located in_____________________________________________________________________________________________________
City and County

From ____________________________________________________________ The waters over which this structure will be placed are
Inclusive dates (dates can not fall outside of March 15 to November 15th)

approximately _________________________________________________________________________________ The structure(s) will
Lake acreage / stream width and length

be located in the vicinity of ________________________________________________________________________________________
Describe nearest reference point(s)

Alternate dates in case primary dates are in conflict with other events or inclement weather

_________________________________________________________________
Alternate date(s)

1. The applicant shall attach, on the reverse side of this application, a detailed sketch of the area over which the proposed structure(s) will be installed. This sketch shall provide a description of the area capable of being fixed and marked to include as a minimum its location in respect to swimming beaches, docks, piers, or other structures used by the general public. Include on the sketch a description of the proposed structure in sufficient detail with respect to design and construction that a determination can be made as to whether hazards might be created by its erection and as to whether the structure could be classified as permanent as defined by 312 IAC 5-4-2. 2. If the structure is determined to be permanent, the applicant must comply with IC 14-25 prior to the permit being approved. Compliance can be accomplished by contacting the Department of Natural Resources, Division of Water. 3. All permits issued for recreational structures on public waters expire on November 15th of the year issued. 4. Navigational markers (aids) shall be colored white with international orange geometric shapes. If placed on water, a navigational aid must be a buoy. Buoys used as navigational aids must conform to U.S. Coast Guard standards.

SITE INSPECTION ( To be completed by Indiana Conservation Officer)
Date application received (Print name) Date of on-site inspection (Signature)

Based on my on-site inspection of_______________________________________________________________________________________
Location

I recommend this application be: Approved as requested. Approved subject to the following modifications: ________________________________________________________________________ _______________________________________________________________________________________________________________ Approval of alternate date / time because: _____________________________________________________________________________ _________________________________________________________________________________________________________________ Denied for the following reasons: ____________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________
Signature of District Commander

District Commander

concurs with inspecting officer. recommends approval of application as submitted.

REGIONAL COMMANDER TO COMPLETE WHEN DENIAL, MODIFICATION OR USE OF ALTERNATE DATES OR TIMES ARE REQUESTED.
Signature of Regional Commander

Regional Commander

concurs with inspecting officer concurs with District Commander

Name of Applicant Address (number and street) (City, State, ZIP Code)

Name of Organization

Telephone number (Include area code)

YOUR APPLICATION IS: Approved (see attached permit)

Denied for reason(s) stipulated under "Site Inspection" above. If denied, you are hereby given notice of your right to a hearing before the Director, Indiana Department of Natural Resources pursuant to IC 4-21.5.
Signature of Law Enforcement Division Director

DISTRIBUTION: Orginal - Applicant; Copy - Division Headquarters; Copy - District Headquarters