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(‘■Vl <br />COMBINED JOINT NOTinCAtlON FORM • 'WATER RESOURCE AFPUCATION ml <br />Use this fam to notiiy/opply to the MioDeloha Cieek Watershed District (MCWD). their eircincctiat coarahuts, the <br />DNR, and the Hennepin Conservation District of a proposed watar/wetbttd project or work tvhich may M within their <br />jurisdictioa Tliose agencies should advise you of their jutisdietioo or pemitrcqairemenls 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 />Shadywo^ Road. Suite 37, Excelsior, MN 5S331. Keepacopy for your records. YOU MUST OBTAIN ALL <br />REOUIRH) AUTHORIZATIONS BEFORE BEGINNING WORK. _______ <br />FhoaeNo. <br />2. Loeatioaof|feposedprc{ieei(Amdiibawla|w/diieaioBStoiiii): ^ <br />CgUI^ QTRaECnON(i) SECnON(t) TOWNS»P(s) RANOE(s) Lot, Block, Suhdi^ <br />PROIECT ADDRESS: 64<^-Tl)^kAliuft RIY CITY: Odi3tJQ <br />eev <br />0-1 <br />OF FILL OR EXCAVATION (Cubic yards): <br />________________i«9 ’ - _________ <br />4 . TYPE OP PERMIT BBING APPLIED FOR: (Cheek all dut^iply): / <br />(^STORMWATER MANAGEMENT PLAN □ FLOODPLAIN ALTERATION <br />T OSTORM SEWER OUIFALLg <br />□ WETLAND ALTERATION <br />(^ORELStE IMPROVE] <br />TQriprap <br />h ^AtbsilANijh' .. , . _ *. .D ice RIDGE REMOVAL <br />c D^ANNOWALL' <br />□bjuD ob R Culvert CROSSWcs <br />OTHER (DESCRIBE)_________________________________________ <br />□jxcavation PR <br />WILDLIFE <br />NAVIOATION <br />BIOENGINEBRING <br />□ •Trti <br />4a. APPLICANT'S REPRESENTATIVE: (Liocued ConiraetDr, Engineer, ete...) litttoteBamt^aAfc^^Rj^oBe number. <br />5. PROJECT PURPOSE (w|^ is this project ftcodod • wbit benefits wQ] It provide?) <br />^fcrUkfJttSO jJAg/JYBVPr___________________ <br />6. a LTERNAT. VBS (describe any other site* or methods diat could be used te achieve dio purpose of your pnject while avoiding or <br />miaimiring wetyAwtlead tamecU. Attach addidoBaltbeels, if needed.. .. »— <br />^ . m .• _ IP7. DATES: Proposed etait ofaetiviiy: <br />fldenti: V any completed work on anaohed diawina) <br />Proposed eompledoii; <br />B. NAME^/j)DRBS^OT^;ODWO PROPERTY OWNERS (Aneh Use if more) <br />9. PERMITS HAVE BEEN RECEIVED (R) OR APPLIED FOR (A) PROM: ^__DNR <br />____C0U1>ITY__^CITY ____MNFOLLUnON CONTROL AGENCY <br />ARMY CORPS OF ENOR <br />I hereby oetiiy the tecipieitts of this fonn of the projeet piopoicd hereta and kqueit Z be advised of a^ permits or.odier detemmatioas <br />colicctniilig this ;smj^ct that I mutt oboia. (undenoind that proesadiBg widi. emk bdotc all requhed aufeaiixadoat aie obtained may be <br />(MuoMry Data <br />r(iloz-' <br />« . • • to^MwdhidlBi