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MA`s-05-2003 15:22 MINNEHAHA CREEK WATERSHED 6124710682 P.03/08 <br /> Cl� <br /> 03-090 <br /> COMBINED JOINT NOTIFICATION FORM-WATER RESOURCE APPLICATION appl <br /> Use this form to notify/apply to the Minnehaha Creels 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.,Dccphaven,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 V 1 it Phone No. . <br /> ' ( r vnsf tv✓t 2.- q79'^24v 17 <br /> Address(Street, Box#,pity.State,Zip) <br /> l r t St[4e*kr( w : <br /> 2. Location of proposed pmj t(Attach wing w/directions to site): <br /> COUNTY <br /> QTR SECTION(s) SECTION(s) RANGE(s) <br /> ) LotBlock,Subdivision44eu • IVEamopse 3z Si a- <br /> PROJECT ADDRESS: 33zC9 tl/ w Mary: <br /> 3. LENGTH OF SHORE AFFECTED(in feet): 7>-7 O VOLUME OF FILL OR EXCAVATION(Cubic yards): <br /> AREA FILLED OR EXCAVATED IS Acres,OR Squarc Fiat. 7 <br /> 4. TYPE OF PERMrr BEING APPLIED FOIL: (Check all that apply): <br /> ❑STORMWATER MANAGEMENT PIAN ❑FLOODPLAIN ALTERATION XWETI.AND ALTERATION <br /> OsHo INEINE iMPROVEMENT DSTORM SEWER OUTFALLS ElEXXCCAD�ON(DRDGING) <br /> a.b SANDBLANXET EICE RIDGE REMOVAL b.CJ NAVIGATION <br /> c AIMING WALL c.LJ mENGIIJEERING <br /> ❑BRIDGE&CULVERT CROSSINGS <br /> OTHER(DESCRIBE) Iyrt r-sm-e e F S dk_-bLgu , _ <br /> 4a. APPLICANT'S REPRESENTATIVE:(Licensed Contractor,Engineer,etc... Include name,address&phone number. <br /> D04� by i l a , �-Zbk4oi f�ye).3 /35 co "., 191ake-ft <br /> 43:;5qt <br /> S.PROJECT PURPOSE(why is this project•needed-what benefits will it provide?) <br /> vh Wv2 41A <br /> 6.ALTERNATIVES(describe any other sites or methods that could be used to achieve the purpose of your project while avoiding or <br /> minimizing water/wetland impacts. Attach additional-sheets,if needcd. <br /> `lL c # h-e nevi G' f 6 - <br /> 7.DATES. Proposed start of activity: ' '6 I�c 3 roposed eomplction: � 3u G 3 <br /> (Ideuti any completed work on attached dmwtn <br /> 8. NAMES&ADDRESSES OF ADJOINING PROPERTY OWNERS(Attach list if more) <br /> 9. PERMITS DAVE BEEN RECEIVED (R)OR APPLIED FOR(A)FROM:_ _DNR ARMY CORPS OF ENGR <br /> COUNTY_ 5.��_CITY MN POLLUTION CONTROL AGENCY <br /> I hereby notify the recipients'of this form of the project proposed liercin and request I be advised of any permits of other determinations <br /> conecming this project that I must obtain.I understand that proceeding with work before all required authorizations are obtained may be <br /> subject to F ral,State and/or local administrarive,civil and/or criminal penalties. <br /> Signalike of Person Proposing 'ect or Agent Date -�• <br />