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AUG-27-2003 12:00 MINNEHAHA CREEK WATERSHED 6124710682 P.02/03 <br /> -tet 0 <br /> COMBIIVED JO1 W NO !MON FORM-WATER RESOURCE APPLICATION wi <br /> Use this form to notify/apply to the MinneWha Creels Waterdkid District (MCWD),their engineering consultants,the <br /> F DNR, and the Hennepin Conservation District of a proposed watt/wetland project or work which may fall within their <br /> jurisdiction.These agencies should advise you of their jurisdiction or permit requitements within 10 days.Fill out this <br /> form completely and mail a copy,with plan,maps,etc...to the MCWD, 19202 Minnetonka Blvd.,Deephaven,MN 55391 <br /> Keep a copy for your records. <br /> YOU MUST OBTAIN ALL REQUMM AUTHORIZATIONS DIWORB BEGINNING WORK. <br /> 1.Applicant's Nemo(Last,First,M.I.) V 1rL Phone No. <br /> Address(Street,RFD,Box#,City,S�izip) ��.r,� -e- <br /> 2. <br /> Z. location of proposed project(Attach drawing w/dimetions to site): <br /> COUNTY QTR SECIION(s) SBCITON(a) TOWNSHIP(s) RANGE(s) Lot,Block,Subdivision <br /> PROJECT ADDRESS: 101-4--7 �dN��w� Ra CITY: � d 1Jd <br /> 3. LENGTH OF SHORE AFFECTED(in fact): VOLUME OF FILL OR EXCAVATION(Cabic yards): <br /> AREA FILLED OR EXCAVATED IS Acres,OR Square Fact. <br /> 4. TYPE OF PERMIT BEING APPLIED FOR: (Check all drat apply): <br /> ❑STORMWATER MANA004ENT PLAN ❑FLOODPLAIN ALTERATION ❑WETLAND ALTERATION <br /> []SHOREY.1Nl?IMPROVEMENT OsToRm SEWER OUTFALLS Jb <br /> 3}CCAVATION(DREDGING) <br /> a.[]WPR.AP WILDLIFEb.[3SANDBLANKET (]ICT?RIDGERRMOVAL NAVIGATION <br /> cLL]]RR�ETTAINING WALL: EIONNOWSLI YG <br /> OBRI]XzE&CULVERT CROSSINGS <br /> OTHER(DESCRIBE) N V,w L'iA 1vc, c..,.t %,T'f" V' 1 <br /> 4a. APPLICANT'S REPRESENTA (I.ioeaeod.C Bzgk eer,oto...) Include name,addtces&phone number. <br /> 5.PROJECT PURPOSE(why is this project needed-what benefits will it provide?) <br /> 6.ALTERNATIV&S(descdU any other sites or methods that could be used to achieve the propose of yarn prgcct while avoiding or <br /> minitnWaig water/wetland impacts. Attach additional shoats,if needed <br /> 7.DATES: Proposed Can of activity: —0 Proposed completion: u <br /> dsttticompleted work on attached drayfiW <br /> B. NAMES&ADDRESSES OF ADJOR41NO PROPERTY OWNERS(Attach list if mora) <br /> 9. raklM PS HAVE BEEN RECEIVED (l)OR APPLIED FOR(A).FROM:_pNR ARMY CORPS OF ENGR <br /> COUNTY CITY MN POLLUTION CONTROL AGENCY <br /> I hereby nod the recipients of this form of the project proposed haein and request I be advised of any peunits or other determinations <br /> that I must obtain I understand that proceeding with work beforo all required aa&mb attons are obtained may be <br /> subje 5 and/or Local administrative,civil and/or criminal pcnalties. 2 /� <br /> sionwre ItVmdo Pr4posing Pipjact or Ageat Date <br /> o A403 aTZ,3 <br /> AN "0 4 206 <br />