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} <br /> • RIED427,110e <br /> COMBINED JOINT NOTIFICATION FORl1 i:-WATER l[EESOURCE APPLICATION app1 <br /> Use this form to notify/apply to the Minnehaha Creek Watershed District (M.CWD),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,Gray Freshwater Center,Navarre,2500 <br /> Shadywood Road,Suite 37,Excelsior, MN 55331. Keep a copy for your records. YOU MUST OBTAIN ALL <br /> REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK <br /> 1.Applicant's Name( ast:,F" M.I.) Phone No. <br /> Address(Street,RFD,Box#,City,State,Zinp�l <br /> 1-1-76:v (,�C 1 I61nJCh'/i D Q ° e/.44 5-536-q <br /> 2. Location of proposed project(Attach drawing w/directions to site): <br /> COUNTY QTR SECTION(s) SECTION(s) TOWN (s) RANGE(s) Lot,Block,Subdivision <br /> p��yn <br /> PROJECT ADDRESS: q 7 to() )- e"'r7___: Oed uJ d <br /> 3. LENGTH OF SHORE AFFECTED(in feet): -er"' VOLUME OF FILL OR EXCAVATION(Cubic yards): 5— <br /> AREA FILLED OR EXCAVATED IS Acres,OR Square Feet <br /> 4. TYPE OF PERMIT BEING APPLIED FOR: (Check all that apply): <br /> El STORMWATER MANAGEMENT PLAN ❑FLOODPLAIN ALTERATION ❑WETLAND ALTERATION <br /> ❑SHORELINE IMPROVEMENT ❑STORM SEWER OUTFALLS El EXCAVATION(DREDGING) <br /> a.CIREPRAP all]bBLANKET [DICE RIDGE REMOVAL b.❑WILDLIFE <br /> . ❑ION <br /> ci RETAINING WALL c.❑BIOENGINEERING <br /> A I <br /> 0BRID9E&CULVERT CROSSINGS <br /> OTHER(DESCRIBE) /`� P‘) fi Mme. J ni r c C• i ,J 4 O r g• AI <br /> .i� 1L :rLa� P ill. / -� ' •iTai iL+ <br /> 4a. APPLICANT'S REPRESENTATIVE:(Licensed Contractor,Engineer,etc___) Include name,address&phone number. <br /> 5.PROJECT PURPOSE(why is this project heeded-what benefits will it provide?) <br /> G.X l setotj64- fir . f s fCcs !a p71.1/2- <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 needed. <br /> IQ ( A- <br /> 7.DATES: Proposed start of activity: 7 /0 Z Proposed completion: r f I 4i <br /> (Identify any completed work on atdcfieii drawing) <br /> 8. NAMES&ADDRESSES OF ADJOINING PROPERTY OWNERS(Attach list if mole) <br /> 9. PERMITS HAVE BEEN)CEIV&) (R)OR APPLIED FOR(A)FROM: DNR ARMY CORPS OF ENGR <br /> COUNTY t/ CITY MN POLLUTION CONTROL AGENCY <br /> I hereby notify the recipients of this form of the project proposed herein and request I be advised of any permits or other determinations <br /> concerning this project that I must obtain.I understand that proceeding with work before all required authorizations are obtained may be <br /> subject to Federal, State and/or local administrative,civil and/or criminal penalties..-ni" r <br /> ►�ih/.d e-U• � �_ 1 Neoe, �, /�-e -v,'J Z- <br /> Signature of Person Proposing Project or Agent Date <br /> SO/20'd Z898TM7ET9 G2HSZI81d('1 I2ild9 1HdHBNNIW PT :ST Eeaz-2E-1nf <br />