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y Permanent Dock Permit Application /oM RanoQ�� <br /> Page 2 (Name) � <br /> 3. Abuttin ro ert owners at the lakeshore: -�I ��/ <br /> Northgor West JtW1, ��WliM.2Ci'h.G.V�. 27�����`��S/�0U � ���'�� `�`f�� <br /> i� (Name and MAILING address) <br /> South or East ichard Ople 277/ Sh�idaWuvd m c�/a�br /!7N <br /> �� (Name and MAIL NG addresa) <br /> Other affected parties <br /> (Names and MAILING addressea - attach sheet if necessary) <br /> 4. Site Lake frontage:2�S� feet; distance of dock into the Lake: 3� feet. <br /> 5. All setbacks for the dock use area have been observed (v)Yes; ( )No. <br /> 6. All required permits, licenses and approvals have been obtained from the City <br /> in which the permanent dock is located, and from the MDNR: ( )Yes ( ) No: <br /> Explain: ��� � L/'I�GD <br /> 7. Fee $ 50 <br /> Permit deposit 100 <br /> Total fee enclosed $150 <br /> I certify that the information provided herein and the attachments hereto are true <br /> and correct statements, and I understand that any permit granted may be revoked by <br /> the District for violation of the LMCD Code. I agree to reimburse the District for <br /> any legal, aurveying, engineering, inspection, maintenance or other expense incurred <br /> by the Diatrict in exceas of the amount of depoait. I consent to permitting of- <br /> ficers and agents of the District to enter the premises involved at all reasonable <br /> times to investigate and to determine whether the Code of the District is being <br /> complied with. <br /> Authorized signature;'� ' <br /> Date ��G/ / Title ��ei� , <br /> Return application and attachments to: Lake Minnetonka Conservation District <br /> 402 East Lake Street <br /> Wayzata, MN 55391 <br /> Phone: (612) 473-7033 � <br /> 12/84 <br />