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CJO)\JIIU*-MJOE*4rN(31MCArl[IICN]EiUItM-WArEMIRENOLIR(:EAPPUCAIION appl Use this form to notify/apply to the Minnehaha Creek Watershed District (MCWD), their engineering consultants, the DNR, and the Hennepin Conservation District of a proposed water/wetland project or work which may fall within their jurisdiction. These agencies should advise you of their jurisdiction or permit requirements within 10 days. Fill out this form completely and mail a copy, with plan, maps, etc... to the MCWD, Gray Freshwater Center, Navarre, 2500 Shadywood Road, Suite 37, Excelsior, MN 55331. Keep a copy for your records. YOU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. 1.Applicant's Name(Last,First,M.I.) Phone No. OL Addr ss(Street, FD,Box#,City,State,Zip) 2. Location of proposed project(Attach drawing w/directions to site): COUNTY QTR SECTION((/s))'' SECTION(ss) TOOWNSHIP(s) RANGE(s) Lot,Block, Subdivision PROJECT ADDRESS: -12MO CITY:O�(i�JO 3. LENGTH OF SHORE AFFECTED (in feet): VOLUME OF FILL OR EXCAVATION (Cubic yards): 2200 GY AREA FILLED OR EXCAVATED IS Acres,OR Square Feet. 2 UDd � 4. TYPE OF PERMIT BEING APPLIED FOR: (Check all that apply): ❑STORMWATER MANAGEMENT PLAN ❑FLOODPLAIN ALTERATION ❑WETLAND ALTERATION ❑SHORELINE IMPROVEMENT ❑STORM SEWER OUTFALLS EXCAVATION (DREDGING) a.❑RIPRAP a.LJ WILDLIFE b.❑SANDBLANKET ❑ICE RIDGE REMOVAL b.❑NAVIGATION c.❑RETAINING WALL c.❑BIOENGINEERING ❑BRIDGE& CULVERT CROSSINGS OTHER (DESCRIBE)--------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------- 4a. APPLICANT'S REPRESENTATIVE: (Licensed Contractor,Engineer,etc...) Include name,address & phone num pr. TV.D /A PME 756 74.wkv- co 5.PR T P RP SE why is this ro'ect needed -what benefit will it rovide� nrPA6"6r44N,0 Bf��lV� ^047bh!OIZAeft �' 1VlrRY G ¢5:5 �tl�'b 40M471k* ^eV2 0"11*W7e 6.ALTERNATIVES (describe any other sites or methods that could be used to achieve the purpose of your project while avoiding or minimizing water/wetland impacts. Attach additional sheets,if needed. #VA,I.—'O 7.DATES: Proposed start of activity: A4y /" Z000 Proposed completion: Avvi "' actro (Identify any completed work on attached drawing) 8. NAMES & ADDRESSES OF ADJOINING PROPERTY OWNERS (Attach list if more))J�Yv` � �N, --------------------------------------------------------------------- ---- ------- -- ---- -------------------------------------------------------------------------------------------------- 9. PERMITS HAVE BEEN RECEIVED (R)OR APPLIED FOR (A)FROM: DNR ARMY CORPS OF ENGR COUNTY CITY MN POLLUTION CONTROL AGENCY I hereby notify the recipients of this form of the project proposed herein and request I be advised of any permits or other determinations concerning this project that I must obtain.I understand that proceeding with work before all required authorizations are obtained may be subject Federal,State a / r local administrative,civil and/or criminal penalties. ---- -- - - - --- ----- - ------------ Si ture Person osm Pro e t or A ent Date