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IT THf pacts RCPNCSENTtO ON TMS <br />It AN ACCUNATt AND TRUI NtMf- <br />INPONMATIOH At IT A^tANt TNIt <br />ItCONOt OP TNt NtHNtOlN COUNTY <br />ION. TO TNt OtST OP NY RNOWLCOCt <br />PINANCt DIVISION <br />property address <br />//?• 2.^ n <br />Aetm <br />^ - /y 7 - -y af <br />p ~/y 7 - -2. ^ <br />■ -/y7- ^9 <br />'^-^tacAmA.*€> . <br />(Rev 74)STATE OF MINNF.SOTA <br />OEPARUCfrr Of NATURAL RESOURCES <br />NOTIFICATION OF PERMIT APPLICATION <br />INSTRUCTIONS FOR THE APPLICANT <br />^^nosota Statutes, Srction 105.44, Subdivision 1, requires you to supply a complete copy <br />all supporting data of your water permit application to the following: <br />A) The chief executive officer of the city or township within which <br />the project is located. <br />B) The secretary of the Board of Managers of the watershed district, <br />if any, within which your project is located or which your project <br />may affect. <br />You WIST certify having served the complete application on the above in the box on the back <br />side ot^the application form W-54. <br />IN ADDITION, if your project is NOT located in a city, a complete copy and all supporting <br />data of the application should be submitted to the A^inistrator of the Shoreland Manage­ <br />ment Program for the affected county. <br />Complete this form for each notice served on a local government official. <br />SECTION 1 (TO BE (XXiPLETED BY APPLICAIITi <br />TO: A) Chief executive officer of the (ohack) <br />city. O township of <br />print or type <br />C) Administrator of the shoreland management program of <br />{print or type name) <br />■ Ml <br />(vrint or t^^ . _ _ <br />county <br />PROM: C* Ron Woloh, Jr, 650 Wo, Irm Dr, Mouad <br />{print or type name and addreee of applicant) <br />'print '6r'type none) <br />Date: April 15 1961 <br />4- Q. <br />N>?0 m| i U' <br />INSTRUCTIONS FOR THE LOCAL GOVERNMENT <br />This report from provides you an opportunity to submit input to the Department of Natural <br />Resources to assist in deciding whether to grant, modify, or deny the requested permit. <br />It is NOT absolutely necessary for local agencies to officially approve or disapprove the <br />project or make any recommendation, although this may be done if desired. It is requested <br />that local agencies indicate the following, as applicable: <br />A. The relationship of the proposed project to local plans for the <br />affected water and related land. <br />B. The relationship of the project to local land use controls including <br />flood plain and/or shoreland regulations. <br />h <br />C <br />(oontimmd on reverse Hde) [j j <br />a ^— - II! <br />may 201901 <br />‘•H' OF OROiV* <br />rc.c <br />'ij <br />_ i