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Permanent Non-Multiple Dock License Application <br /> 4. Site lake frontage:, feet; distance of dock into the lake: feet. <br /> 5. All setbacks for the dock use area have been observed ( )yes ( ) no. <br /> 6.All required permits, licenses and approvals have been obtained from the city in which the <br /> permanent dock is located, and from the DNR: ( ) yes ( ) no <br /> Explain: <br /> 7. Application Fee $150.00 <br /> After-the-fact application fee $150.00 <br /> Total Fee enclosed $ <br /> I certify that the information provided herein and the attachments hereto are true and correct; I <br /> understand that any license issued may be revoked by the District for violation of the LMCD <br /> Code. I agree to reimburse the District for any legal, surveying, engineering, inspection, <br /> maintenance or other expenses incurred by the District in excess of the amount of the <br /> application fee. I consent to permitting officers and agents of the District to enter the premises <br /> at all reasonable times to investigate and to determine whether or not the Code of the District is <br /> being complied with. <br /> I agree to submit . -rtified, as-built survey upon completion of the docks. <br /> /—/?— <br /> Autborized <br /> Signa ure Date <br /> r <br /> eller a( i2lungyv <br /> Title <br /> //�� <br /> Lel°CVY4C1' V Return this application,attachments and fee to: <br /> Relationship to Owner <br /> Lake Minnetonka Conservation District <br /> 18338 Minnetonka Blvd. <br /> Deephaven, MN 55391-3232 <br /> Fax: (952) 745-9085 <br /> 2 of 2 <br />