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FEE �c� 1'�'�+� 14�4'� 1�1I�l�JEHHHH �=F'EEF' I,IHTEF"=;HEL� 61�471�=��''� F'.�=r� 't=�� <br /> SANDSL,A.�II�ET PE�.M�T & S,F�.�1la S�L7RCE E�HrBIT FORM <br /> MINNEI�AI-�A CREEK W�TEP�SHED DIS'1'RICT - <br /> P�P�MIT 97 � '� � <br /> 1,� anrt_ ����n� rcysidin}� nt_ ��1�� _ �i�a c.-a b +f�C �h.c`rw � �S���__ <br /> Fit�perty Qwncr Addtrss (;itY,State,Zip <br /> '�f��1 - ��og _ _ �.�- , orPTD# � -11"7- �3 �-�-voo-� <br /> Plionc County Tu�vnship,Scetipn,R�nge (E�rx�m pmperfy tax�teme»t) <br /> 'own attd occupy the above single f�mily residet�,ce and w�sh ta install a s�.ndblanket on <br /> Y`i?�-k a - ��� ��k <br /> �xr&$�Y ------ <br /> . �:--��-. <br /> � GO�C�"f�UN06CAP�Nc� <br /> [� I have contractec�with r� at �)S�S PR1 <br /> Iiccnsed coiifractor ',;._�..` � c�� <br /> , to install clean san� frozn the falIowing sour�e: <br /> cit_y,sfntc,zip �?hone <br /> ��� `�`..�' a�-�-- 'C�-��c� , '`��5/g-�}/7 � ,Or: <br /> stipplir.r addr��s ��Il6t1C <br /> ❑ t will ie�stfil� �}1�. $t121C�1�li3Yl�C� YCi��1Clf�IOItl E�lG f0110W1Y1�,T SOL1CCe. � <br /> sti�5��licr <br /> - - > <br /> sdcir�s.s phonc <br /> If this pr�je�f �-equz��es municipal approval or review, p�ease attach �ocu���erttati4�t1 of t1t� �rtu.r��cipa] approval <br /> w�tl� tltis ap�l�cai-ion. My sjlor•eIine is $� feet<�nd thc ditncnsiotls bf t�1c propost.d saildbl��nke_t �ir�.: <br /> `'��� (Ixn��;th) x-�_� (wic�th} x �� (�zpth). S1ndblanket diizl�nsiorts cannot e�;ceec� F3 <br /> lei���t}i of;0' (or �0'% of s}Zoreliiie), a widt}l af 10�i12lC�I � (IC�.�t�l C�f ���. . <br /> I uttidet'stattd th��t il tllis ap}�licatioti is noi co�nplcte;ly filled out, ar if i fail to �L1��IYllt f{1� i��L�L11Y"�L� �Yhik�it,, <br /> flie ap��lc�aiion is irlc:ottiplete �r�d �.�riJl l?e r�E�irne:c�. It �uill 11ot }�e �'e.�Jie���ed �iy MC\�'L� staff tiritil complete_ <br /> L-�y sigi�in�; tjtis �1��pli��tiorl, I a�,ree ��nd urlae�siand that thc L�ititri�t Itl�i�� enter the proper-ty at i�easanable <br /> fli����-s Eo corlduct at� in.Sp�:�Eian to c�eterinirie w�tefh�r t�tc- t�rttt5 of tllc pertnit a.re bein� mct. I turther <br /> tirtc���t'yland th.it if I violate t�1� fcrms �t1d conditiorls of a ��ertnit thak ts is9�_t�'d bi�S���l lzpbtt t�lts �ipplicFif1011, <br /> t11e �)��tr1Ct S�lall CL�TlL�tdC� Z flC�a IItS�C�'tlOtl Ot flle j71"O��C.L �i�� MC�W� �'UI� J, �7rl�Vll�l'4� Wlt�l t�lly �ij?pI1C=�i�lOtl. <br /> I un,dea•stattd thr� L7ist�•ict ��vill cha���e fees E�i covci•#}te actu�l cost5 of .fi.e.ld ittsrt-�:fic}iis, 1Il(:II.iC�121`y 1t1VCStly<�tiost <br /> or t�ie area affeckcd by the �uor.�k, i1I1cl��tti��; �]l f�lE: \�IO?'�, 1}IL�UC�IkI��;, f}l� 4�CVLC�S (7f ��:�y'.il l'UlII1SC'� fiL1C� 4Tl�;lIZCC1'ti� <br /> ilYlC� 1}1y' �U�S�i�U4=llt ITlO1l1tOT'1}l� OF i}lr W�7T-�i. r�1C �LStk"1Cf�ti 3CtL1R1 COSfS ��Y�� C�C��t'Tll�� �����i}Y�,��l,�}kI'�1����'LC=tl <br /> t�ie Dis�rict issiles natic-c of rlte. viola[iott to Eh� permittee. [ �tave read attd uttd��rst�lhA6t�t�����'f�I��h�iT��il <br /> G �lin��s�for�•.�� bJan ets. <br /> �� � .,�--�, ;, - ��� 2 5 19�7 <br /> 1 ��� �/�7 <br /> Si�klatUt'� of property �± ler C)atc <br /> � � <br /> tiu��.c�ribcd a��d sworxi to befdre ���e t}lis � d��y of�� 1�)9 7 . � �-� '�.J�" ;�� � �,� =.e � <br /> YhI�/.tnn.1++Y�.��•••ww/,.w wt.rrv..�..... <br /> � - ,��-ir.� �1E�'.�err'cJ i"J!`�G`C�'LCJ��"JJI�C'J <br /> ��u,ii'�I'�h;l ����,i�.�:1'PC'CLlC-t:��:lh�'"�TA <br /> ���;::����`;��; r��i�.n3u_����a c��ra�v <br /> NOt T �11U11[; ,li��a�n�'� htyca�er+7'ian4xplrc91�7-�Cs44 <br /> !--'' ��� �� <br /> App�-Qv and Acceple�i by Date <br /> ��IZ;�n . We�dtnai�t, Ass1St�lnt Directok' sanclI -Jan�7 <br /> TLiTHL F'.�=t� <br />