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�., <br /> � � � C� PY. �G -3� ������.. <br /> �- � � <br /> COMBINED JOINT NOTIFICATION FORM-WATER RESOURCE APPLICATION �p� <br /> Use this form to notify/apply to the Minnehaha Creek Watershed District (MCWD),their erigineering consultants,the <br /> DNR,and the Hennepin Conservation District of a proposed water/wetland project or work which may fall within their <br /> jurisdicrion. These agencies should advise you of their jurisdiction or permit requirements within 10 days.Fill out this <br /> fonn completely and mail a copy, with plan,maps,etc...to the MCWD,Gray Freshwater Center,Navarre,2500 <br /> Shadywood Road, Suite 37, Excelsior, MN 55331. Keep a copy for your records. YOU MUST OBTAIN ALL <br /> KEQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1.A licant's Name(Last,First,M.I. Phone N . <br /> G D � ��l' z '��7�• �tv�0 <br /> ess�,Stre BQ,�j#,� , State,Zi <br /> EJ l C�j � � I <br /> 2. Location of proposed project(Attach drawing w/direcrions to site): <br /> COUNTY QTR SECTION(s) SECTION(s) TOWNSHIP(s) RANGE(s) ' �t,Block,Subdivision <br /> PRO7ECT pDDRESS: � 1 I? Z�J ,.," � 3 �(�.� <br /> CITY: � /��7 <br /> 3. LENGTH OF SHORE AFFECTED(in feet;: VOLLJb�OF FII,L QR EXCAVATIGN(Cubic yards): <br /> AREA FTLLED OR EXCAVATED IS Acres,OR'�.�'� Squaze Feet. <br /> 4. TYPE OF PERMIT BEING APPLIED FOR (Check all that apply): <br /> ❑STORMWATER MANAGEMENT PLAN ❑FLOODPLAIN ALTERpTION �WET'L,pND qI,TERqTION <br /> ❑SHORELINE IMPROVEMENT ❑STORM SEWER OUTFALLS ❑ EXCAVATTON(DREDGING) <br /> a.[]RIPRAP a.0 WILDLIFE <br /> b.�SANDBI,ANKET �ICE RIDGE REMOVAL b.�NAVIGATION <br /> c.�RBTAINING WALL c.�BIOENGINEERING <br /> OBRIDGE&CUI.VERT CROSSINGS <br /> OTHER(DESCRIBE) <br /> 4a. AP LI 'S RE�P�W i�:(L,} i�ed ContractoryEngineer,etc... Incl�ude�name,address&phone nurnber. <br /> �1�l�r V�1 1 a `�' SC�JD�A ��� 3 Z , Z Z <br /> 5.PR07ECT PURPOS�(why is this project needed-what benefits will it provide7) <br /> T� �►(�l t-�'o/�?�--� NT 1�j�c�� <br /> 6.ALTERNATIVES(describe any other sites or methods that could be used to achieve the purpose of your project while avoiding or <br /> minimizing water/wetland impacts. Attach addirional sheets,if needed. <br /> �� <br /> 7.DATES: Proposed start of activity: �Q�j 2 2�� Proposed completion: �'� yl� �2��,._. <br /> (Idenrify any com leted work on attac�ed c�rawing <br /> 8• NAME����S OF ADJOINING PROPERTY OWNERS(Attach list if more) <br /> 9. PERMITS HAVE BEEN RECEIVED (R)OR APPLIED FOR(A)FROM: DNR ARMY CORPS OF ENGR <br /> COiJNTY CITY MN POLLUTION CONTROL AGENCY <br /> � <br /> I hereby notify the recipients of this form of the project proposed herein and request I be advised of any permits or other determinations <br /> concem I btain.I understand that proceeding with work before all required authorizations are obtained may be <br /> sub' e• an •local adm ' trarive,civil and/or criminal penalries. <br /> �,%�i C���'f�'L <br /> Si atu ers o osin ro'ect or A nt Date <br /> V�- <br />