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JAN-04-2001 16:48 MINNEHAHA CREEK WATERSHED 6124710682 P.02iO4 SANDBLANM P Wff & SAND SOURCE EXMIT FORM AMNULAM CREEK WA DISTRACT -PERMff 00 41(a I, oy11 s.Qo� �B'WiAsiding at ) n y o T'o-rt f�4 U/� ss3S6 Propelty owner AMMU City,State,Zip -LI-I I - 'S 9 5 I . or PID# OS-I 1 -a3 i 3 00 13 Phone county Tawnsidp,section,Rath On=property tax statement) own and occupy the above single family residence and wish to install a sandblankat on W)►k d- - -Yl�l•c WA.4 ..CONCEPT LANDSCAPING Lake&Day ^..:..,3158 PRIEST LANE MOUND. MN 65364. ; I have contracted with mclat col� or addnas to install clean sand from the following source: city,state,zip 5 Q.,,�.� _ ��..ae,S� , yN 8 --1 r-�S ,or. supplier address phone ❑ I will install the P"dbh=ket myself from the following source. , suppticr addre a phone. if this project requires municipal approval or review,please attach documentation of the municipal approval with this application. My shoreline is I 10 feet and the dimensions of the proposed satidblan)W are. Sip (Length) x I " (Width) x (Depth). Sandbhmket dimensions cannot exceed a length of 50' (or 50%of shoreline),a width of 10'and a depth of 6A. I understand that if this application is not completely filled out, or if I fail to submit the required exhibits, the application is incomplete and will be returned. It will not be reviewed by MCWD staff until complete. By signing this application, I agree and understand that the District may enter the property at reasonable hours to conduct an inspection to determine whether the terms of the permit are being met. I furtherl understand that if I violate the terms and conditions of a permit that is issued based upon this application, the District shall conduct a field inspection of the project per MCWD Rule J, provided with this application. I understand the District will charge fees to cover the actual costs of field inspections,including investigation of the area affected by the work,analysis of the work, including the services of legal counsel and engineers,' and any subsequent monitoring of the work. The Districts actual coats are deemed to begin accruing when the District issues notice of the violation to the permittee. I have read and understand the MCWD Technical: Guidelines for sandblankets. Sig tore of property owner Date Subscribed and sworn to ore this Z-s+L day of 0 a't 00 . ■ JAMES I %SMITH u NOTARY ?.IWN "F=A COMMISSION EXPIRES 1414= Nota Public MF mmmm"AAAA AAA y o/ Approved d Accepted by Date Tames Haffher. i)islrinf Trr1,s„�ian .r