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<br /> COMBINED JOLNT NOTIFICATION FORM- WATER RESOURCE APPLICATION e��i
<br /> Use this form to notify/apply to the Minnehaha Creek Watershed District (MCWD), their engineering consultants, the
<br /> DNR, and the Hennepin Conservation District of a proposed water/wetland project or work �vhich may fall �vithin their
<br /> jurisdiction.. "i�ese agencies should advise you of their jurisdiction or permit requirements �vithin 10 days. Fill out diis
<br /> form completely mail a copy, with plan, maps, etc... the MCWD,Gray Ereshwater Center, Navarre, 2500 Shadywood
<br /> Road, Suite 37, Excelsior, MN 55331. Keep a copy for your records. YOU MUST OBTAIN ALL REQUIRED
<br /> AUTHORIZATIONS BEFORE BEGINNING WORK.
<br /> 1. Applicant's N me(Last, Fi t,M.I.) /Phone No.
<br /> S�..M;� QdIJ�, wS 2 . O/ Z �i��� 3��'�V �
<br /> Address(Street,R�D,Bo�C€F, City,Sja[e,Zip) �, � �c�G ) ���q
<br /> I��' S ,S �,.e�-e�(, �-e, alr'��, ,��� d _
<br /> 2. Location of proposed project(Attach drawing w/directions to site):
<br /> COUNTY QTR SECTION(s) S�CI'ION(s) TOWNSHIP(s) RANGE(s) Lot, Block, Subdivision
<br /> PROJECT ADDRESS: Sc.,n.�-�, �, c, e v`��
<br /> 3. LENGTH OF SHORE AFFECTED(in feet): VOLUME OF FILL OR EXCAVATION(Cubic yards):
<br /> AREA FILLED OR EXCAVATED IS Acres,OR Square Feet.
<br /> 4. TYPE OF PERIv[IT BEING APPL�D FOR: (Check all that apply):
<br /> � STORMWATER MANAGEMENT PLAN ❑ FLOODPLAIN ALTERATION ❑ WETLAND AI-TERATION
<br /> ❑SHORELINE IIvIPROVEIvtENT ❑STORM SEWER OUTFALLS ❑ EXCAVATION(DREDGING)
<br /> a.❑ WILDL�'E
<br /> b.QSANDBLANKET ❑ICE RmGE REMOVAL b.❑ NAVIGATION
<br /> c.QRETAINING WALL c.❑ BIOENGINEERING
<br /> p / ❑BRIDGE&CULVERT CROSSINGS
<br /> OTI-�R(DESCRIBE) /�--¢.PI�C� �d wT IZ�-�^P --
<br /> 4a. APPLICANT'S REPRESENTATIVE:(Licensed Contractor,Engineer, etc...) Inc(ude name, address&phone number.
<br /> `—�.��6�✓`��e r �.,.,c. �v 13�1oL Z1`� �S"!- .�a.,.,"���,�..,e 3333.�
<br /> 5. PROJECT PtJRPOSE(why is this project needed-what benefits will it provide?) '
<br /> �e,��,., o/� l�a q,���f'� l�.c,:,.. �uv e� �.->,t�. �c1,,�� —/�.TS J"�'
<br /> 6. ALTERNATIVES (describe any other sites or methods that could be used to achieve the purpose of your project while avoidinEs
<br /> or minimizing water/wetland impacts. Attach additional sheets,if needed.
<br /> 7. DATES: Proposed start of activity: �-� �^-� c/ �'� Proposed completion: �� =�E'l— �9� �
<br /> (Identify any completed work on attached drawing)
<br /> 8. NAMES & ADDRESSED OF ADJOI PROPERTY OWNERS(A ach list if more)I �
<br /> ✓J/%•... �.� L,s-�., L�) -?/ / � 8� �0�/���� Gl�'�, Z �
<br /> Q n. d�� �� ' a�" — 6 r, " d 2 c� G-er— S'
<br /> 9. ERMI HAVE BEEN RECEI D (R)OR APPLIED FOR(A)FROM: D ARMY COR.PS OF ENGR
<br /> COUNTY CITY , MN POLLUTION CONTROL AGENCY
<br /> [ hereby notify the recipients of this form of the project proposed herein and request I be advised of any permits or other
<br /> determinations concerning this project that[must obtain. I understand that proceeding with work before all required authorization�
<br /> are obtained may be subject to Federal, State and/or local administrative, civil andJor crimina penalties.
<br /> � � � �
<br /> Signature of Pe n Proposing Project or Agent Date
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