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Pernumcnt Non-Multiple Dock License Application <br />4. Site lake frontage; i feet; distance of dock into the lake: "1 ^__feet. <br />5. All setbacks for the dock use area have been obscr/cd ^ yes ( ) no. <br />6. All required pennits, 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:, lk^‘ ______________ ___________________________ <br />7.Application Fee...........................................SISO.OO <br />Afrcr-tlie-fact application fee........................$150.00 <br />Total Fee enclosed.......................................$ <br />I certify that the information provided herein and the attachments hereto are true and coirect; 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 />maintennnee or other eipenses incurred by the District in cicess 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 tlie Code of the District is <br />being complied with. <br />I agree to submit a certified, as-built survey upon completion of the docks. <br />Z-/in /f>^ <br />o7tt <br />hoc <br />Tint <br />"PcOA \fCifirfAiF.lLjCCLX:C.Pc\t>P Return this application, attachments and fee to: <br />RditfoRtliip to OwBcr <br />Lake Minnetonka Conservation District <br />18338 Minnetonka Blvd. <br />Deephaven, MN 55391-3232 <br />Fax: (952) 745-9085 <br />^ 0 2005 <br />2 of 2 <br />mm