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�'�'% <br /> j �."°�''��:��� �"�'' y ����.r <br /> �LR` . . �� � P, '�: <br /> COMBINED JOINT NOTIFICATION FORM-WATER RESOURCE APPLICATION appl <br /> Use this form to notify/apply to the Minnehaha Creek Watershed District (MCWD),their engineering consultants, the <br /> DNR, and the Hennepin Conservarion District of a proposed water/wetland project or work which may fall within their <br /> jurisdiction. These agencies should advise you of their jurisdiction or permit requirements within 10 days. Fill out this <br /> form completely and mail a copy,with plan,maps,etc... to the MCWD, 18202 Minnetonka Blvd.,Deephaven,MN 55391 <br /> Keep a copy for your records. <br /> YOU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1.Applicant's Name(Last,F�j'�st,M.I/) Phone No. <br /> ���i Ik �fC�� i H.-� �>��-�/'�` -:v�� <br /> ,✓� O c�` r , /� <br /> Address(Street,RFD,Box#,City,State,Zip) <br /> 3 / ;v�., „�!l l:-,� <br /> 2. Location of proposed project(Attach drawing w/direcrions to site): <br /> COLJNTY QTR SECTION(s) SECTION(s) TOWNSHIP(s) RANGE(s) Lot,Block,Subdivision <br /> PROJECT ADDRESS: � !�O .5hu� i�✓D� '\iit CITY: � �/)!��> <br /> 3. LENGTH OF SHORE AFFECTED(m feet):Q VOLLJME OF FILL OR EXCAVATION(Cubic yards): <br /> AREA FILLED OR EXCAVATED IS Acres,OR Square Feet. <br /> 4. TYPE OF PERMIT BEING APPLIED FOR: (Check all that apply): <br /> ❑STORMWATER MANAGEMENT PLAN ❑FLOODPLAIN ALTERATION ❑WETLAND ALTERATION <br /> ❑SHORELINE IMPROVEMENT ❑STORM SEWER OUTFALLS ❑ EXCAVATION(DREDGING) <br /> a.�RIPRAP a.�WII.DLIFE <br /> b.�SANDBLANKET ❑ICE RIDGE REMOVAL b.❑NAVIGATION <br /> c.ORETAINING WALL c.�BIOENGINEERING <br /> � ❑BE�IDGE&CULVERT CROSSINGS <br /> OTHER(DESCRIBE),��� ��9���� ' K� b��.4� %�'�•�`� <br /> 4a. APPLICANT'S REPRESENTATIVE:(Licensed Contractor,Engineer,etc...) Include name,address&phone number. <br /> 5. PROJECT PURPOSE(why is this project�eeded-what benefits will it provide?) <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 additiona(sheets,if needed. <br /> 7. DATES: Proposed start of activity: �i:, �y Proposed completion: ��>= <br /> (Identify any completed work on attached drawing) <br /> 8. NAMES&ADDRESSES OF ADJOIMNG PROPERT'Y OWNERS(Attach list if more) <br /> 9. PERMITS HAVE B�EN RECEIVED (R)OR APPLIED FOR(A)FROM: DNR ARMY CORPS OF ENGR <br /> COUNTY�CITY MN POLLUTION CONTROL AGENCY <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 /> concerning this project that I must obtain.I understand that proceeding with work before all required authorizations are obtained may be <br /> subject to Fe�al,State d/or 1 r�al�ministrative,civil and/or criminal penalties. <br /> ` <br /> i <br /> ,� �-,-�='� s/ �� <br /> Si`nature of Person o osin Pro'ect or A ent Date <br />