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COMBINED JOINT NOTIFICATION FORM-WATER RESOURCE APPLICATION WO <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 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,First,M.I.) Phone No. d5a—x/76 a�7 <br /> Q C��Tsru.� -:74-u f <br /> Address(Street,RFD,Box#,City,State,Z' ) <br /> 1,g 2-13 iD- vu,� 5 j <br /> 2. Location of proposed project(Attach drawing w/directions to site): <br /> COUNTY QTR SECIION(s) SE jCTION(s) TOWNSHIP(s) RANGE(s) Lot,Block,Subdivision <br /> PROJECTADDRESS: CITY: 6NZQW ._ <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 PERMIT BEING APPLIED FOR: (Check all that apply): <br /> ❑STORMWATER MANAGEMENT PLAN ❑FLOODPLAIN ALTERATION ❑WETLAND ALTERATION <br /> REUNE HaROVEMENT []STORM SEWER OUTFALLS � ON(DREDGING) <br /> �� WILDLIFE <br /> b.OSANDBLANKET []ICE RIDGE REMOVAL b.CJ NAVIGATION <br /> c.( MAINING WALL c.[]BIOENGIIamING <br /> []BRIDGE 8c CULVERT CROSSINGS <br /> OTHER(DESCRIBE) Ek a S 10 W C 6 n/12 4 �L -- <br /> 4a. APPLICANT'S REPRESENTATIVE:(Licensed ContsacW,Engineer,etc...) Inchde name,address&phone number. <br /> �n-�,• — ._ �vlvi� a�Coi�- Gni?7!S/67> <br /> 5.PROJECT PURPOSE(why is this project needed-what benefits will it provide?) <br /> G7�fL:c G <br /> 6.ALTERNATIVES(desmbe 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 additional sheets,if needed <br /> 7.DATES: Proposed start of activity: `7 3—C)3 Proposed completion: <br /> g4q�4 any completed work on attached drawing) <br /> 8. NAMES&ADDRESSES OF ADJORM40 PROPERTY OWNERS(,Mach list if more) <br /> 9. pMM1 S HAVE B (R)OR PLIE1D A)FROM:_,__DNR ARMY CORPS OF ENGR <br /> COUNTY )k _ MN PO ON CONTROL AGENCY <br /> I hereby notify the recipients of this form of the project proposed herein and inquest I be advised of any permits or other determinations <br /> Pconcen ject I ust obtain.I understand that proceeding with work before an required authorizations are obtained may be <br /> I to Federal, r local administrative,civil and/or criminal penalties. <br /> LZ 0-3 <br /> S' of Person ect or Dater <br />