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MAY-17-2000 11:05 MINNEHAHA CREEK WATERSHED 6124710682 P.02/02 <br /> SAN17BLMM PST& SA,M SOURCE E)a-UBff FORM <br /> MMUMHA CUM WA DWMCT <br /> oa - <br /> 1, S„►� •ding at a"i o �� Pond" SS3� <br /> Pwpem Owner Address Q%sate,zip <br /> L -t t - Q+ $-A n - - or Fn)#a I a:3 3 o a 5 <br /> Phone Com Tom,,g Rarer (from property tax stateroent) <br /> own and ocaupy the above single fancily ridence and wish to install a awdblankiet on _K <br /> �Gl. l:0►N'�*^^'�- W AT E i=i S,;-IED L)f S'f rt 1 u T <br /> Lake&8`y CONCEPT LANDSCAPING MAY 10 2009 <br /> [� I have contracted with 3153 PRIEST LANE at <br /> to inst4 clean sand�t(w"fidid ►gry sou r x. <br /> dw,sesta, 1 <br /> supplier �ddresa phones <br /> Q I 1 the sandbianket myself from the following sourm mipplier <br /> ? <br /> if this project rtmgWm municipal approval or review,please attach documcu anon of the rnunicipal approval <br /> with this application. My shoreline is111 G feet and the dimensions of the proposed xandblanket M. <br /> So (Length} x .1-0. _. (width) x ��� (Depth).sattdblanlaet dimensions cannot exceed a <br /> length of 50' (or W%of shoreline),a width of 1 W and a depth of V. <br /> I understand that if this application is not completely tilled out, or if I fail to submit the required exhibits, <br /> the application is incomplete aced will be returned. It will not be reviewed by MCWD staff until complete. <br /> $y signing this application, I agree and understand that the District may entor the property at reasonable <br /> boars to conduct an inspection to determine whether the terms of the permit are being met. I further <br /> understand-that if I violate the terms and conditions of a permit that is issued based upon this application, <br /> the District shall conduct a field inspection of the project per MCWD Rule J, provided with this application. <br /> I undczstand the District wM charge fees to cover the actual costs of field inspections,including iuvestigation <br /> of the area affected by the work,analysis of the work, including the services of legal counsel and engineers, <br /> and any subsequent monitoring of the work The District's actual casts are deemed to begin accruing when <br /> the District issues (notice of the violation to the permittee. I have read and understand the MCW0 Technical. <br /> lines f lankets. <br /> signature of proI7erty owner <br /> subscribed and sworn to before me this day of <br /> _ KRISTINA L GARIN <br /> M� NOTARY pU.L' T;4NIJ�SOTA <br /> tai`y b My Comr,.:w:ic-j Jon 31,2D05 <br /> RA.4- <br /> ij;mvolAnd Accepted by Date <br /> TavnPc Msf»wr r?i� nt Ti�1�++iriar� <br /> TOTAL P.02 <br />