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MAY-05-2003 15:22 MINNEHAHA CREEK WATERSHED 6124710682 P.03/08 <br /> C000� <br /> � <br /> n 0 <br /> V <br /> COMBINED JOINT NOTIFICATION FORM-WATER RESOURCE APPLICATION <br /> Use this form to notify/apply to tho 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.,Decphaven,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.) �`,�'�j 0 h Phone No. Z- 7 <br /> CC..dd r ✓1 7S"� <br /> Address(Street,RFM Box#,Pty.State,Zip) <br /> 1 r ci�ve w 3 q <br /> 2. Location of proposed prof t(Attach dmwing w/directions to site): <br /> COUNTY QTR SECTION(s) SECTION(s) TOW�) RANGE(s) Lot,Block,Subdivision <br /> IV E G1;f2o�5C^ gz I �3 <br /> PROJECT ADDRESS: 7;-162 J Mary: r2' <br /> 3. LENGTIi OF SHORE AFFECTED(in foot): 737 O VOLUME OF FILL OR EXCAVATION(Cubic yards): <br /> AREA FILLED OR EXCAVATED IS Acres,OR Square Feet. 7 A1,,7V <br /> 4. TYPE OF PERMIT BEING APPLIED FOR: (Check all that apply): <br /> ❑STORMWATER MANAGEMfiNT PIAN '❑FLOODPLAIN ALTERATION A(WETI.AND ALTERATION <br /> QSHOO�IMPROVEMENT OSTORM SEWER OUTFALLS F1DEXCAL�ON(DRE130MG) <br /> a.EIRUb SANDBLANKET DICE RME REMOVAL bE NAVIGATION <br /> C AINIl�TG WALL c BIOENGINEERING <br /> ❑BRIDGE&CULVERT CROSSINGS <br /> OTHER(DESCRIBE) 9.,CTC,.tb% <br /> 4a. APPLICANT'S REPRESENTATIVE:(Licensed Contractor,Engineer,etc..) Include name,address&phone number. <br /> Dotl� I'�-v i lC6^� q" �?o <br /> * w1 ��� •3y35 Co lam.• l o I <br /> 5.PROJECT PURPOSE(why is this project•needed-what benefits will it provide?) <br /> IA pkojoR 4AA atp_"F core <br /> 6.ALTERNATIVES(describe any other sites or unctbods that could be used to achieve the purpose of your project while avoiding or <br /> minimizing water/wedand impacts. Attach additional-sheets,if needed. <br /> w g i aal— h b f y fie. . <br /> 7.DATES: Proposed start of activity: ' 5 1 O 3 'reposed completion: (01-4 0 c1 3 <br /> (Id6wilyaay co letcd work on attached drawing) <br /> 8. NAMES&ADDRESSES OF ADJOINING PROPERTY OWNERS(Attach list if more) <br /> 9. PERMS 13AVE 13F N RECEIVED (R)OR APPI:IE•D FOR(A)FROM:;_DNR ARMY CORPS OF ENGR <br /> COUNTY IX_CITY MN POLLUTION CONTROL AGENCY <br /> I hereby notify the rccipients'of this form of the project proposed horcm and request I be.advised of any permits or other determinations <br /> concerning this project tbat I must obtain.I understand dW proceeding with work before all required authorizations are obtained may be <br /> subject to Ft",State and/or Iocal administrative,civil and/or criminal penalties. <br /> Si a of Person proposing act or Agent Date "'^•■-+�+eF <br /> • -a.� <br /> }k�'i 31;xN{�• _ <br />