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LAKE SHORELINE STABILIZATION <br />PERMIT APPLICATION FORM <br />MINNEHAHA CREEK WATERSHED DISTRICT (MCWD) <br />15320 MINNETONKA BLVD. Ph: 952-471-0590 <br />MINNETONKA, MN 55345 Fax: 952-471-0682 <br />1. Property owner information - <br />Name of each property� owner: <br />Mailing Address: <br />Email <br />6wy\r Stater Zip:3_2�� <br />C)V, Phone: <br />2, Contracting company information(: <br />Business Name:/jAas P U IRepresentative Narne: /(��'"� G {i tGL <br />Business AddressS66 0, ze, /j Cityi�)kak-k lt d State: � Zip: / <br />Email Address: 16(M ® . 1 V\ f C � to t�— Phone: 9(� / � V — < 11/sv <br />Ongoing performance bond with MCWD: Ayes [I No Bond Number: /— t ' -e <br />3. Project Details: <br />/% /�, <br />Project address: �rV ��`� City: CJ ��� State: Zip: ����j� <br />County: [+- & vt Property ID number (PID):_D d) i 2 2 � ` � 06 1 <br />Type of Project: ❑ Vegetative restoration ❑ Bioengineering (XRiprap ❑ Retaining wall <br />In-kind replacement: f'Yes ❑ No Erosion intensity score (if not in-kind replacement): <br />Located on lake:! Y u\��� Length of shoreline affected: tJ[/ i (lineal feet) <br />Describe any existing structure along shoreline: k0(k <br />Access to project site by: ❑ Ice <br />Financial assurance bond acquired: <br />Barge ❑ Upland corridor <br />❑ Yes ❑ No (If not an ongoing performance bond please fill out next page) <br />By signing below, I hereby request a permit to authorize the activities described herein. I certify that I am familiar with MCWD Rules and that <br />the proposed activity will be conducted in compliance with these Rules. I am familiar with the information contained in the application and, to <br />the best of my knowledge and belief, all information is true, complete and accurate. I understand that proceeding with work before all required <br />authorizations are obtained may be subject to federal, state and/or local administrative, civil and/or criminal penalties. <br />r <br />Signatu e of roperty owner or ontracting representative Date <br />Page I of 2 <br />