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I <br />P-Vl <br />COMBINED JOINT NOTmCATlON FORM - WATER RESOURCE AFFUCATION ml <br />Use this form to notiiy/apply to the Minnehaha Creek Watershed District (MCWD). their encinccring consultants, the <br />DNR, and the I’lcnnepin Conservation Dbtrict of a proposed water/wetland project or work which may foil within their <br />jurisdictioD. Tlicsc agencies should odvise you of their juiisdictiou or permit requirements ithin 10 days. Fill out this <br />form completely and mail o copy, with plan, maps, etc... to the MCWD, Gray Freshwater Center, Navane, 2S00 <br />Shadywo^ Road, Suite 37, Excelsior, MN SS331. Keep a copy for your records. YOU MUST OBTAIN ALL <br />REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br />Address (Strait, Jtfp, Box #, City, Sute. Zip) <br />2. Loeatioaori«opasadpro!ject(Atachdrawiagw/ditectio(iiiosi<«); <br />COUNTY ^ QTR SECTCONCs) SECT10N(s) TOWNSHl?(i) RANGE(i) <br />PROIECT ADDRESS: 64^’TtuJkAUjft tTi_______OTY; Ogi3lJQ <br />Lot, Block, Subdii^bjop <br />CV.l <br />3. ^ excavation (Cubic yarfi); <br />_________________l«9 <br />4.. TYPE OF PI JtMIT BEING APPUEO FOR: (Check aU that apply): / <br />^STORMW a TERMANAGEMENTPLAN □ FLOODPLAIN alteration <br />P^OREUirEIMPROVEMBNT DSTORM SEWER OUTFALLS <br />a JIUPR a P <br />bOSANDBlANKET ... . ..□iCEWDGEREMOVAL <br />□bJUDOB & CULVERT CR0S51NCS <br />□ WETLAND ALTERATION <br />□ excavation (DREDGING) <br />aO WILDLIFE <br />h.D N avigation <br />cjj BIOENCINEERJNO <br />OTHER (DESCRIBE) <br />4a. APPLICANT’S REPRESENTATIVE: (Licensed Contractor, Engineer, etc...) toclu^^nante^aAka^^A^hone nuirbq. <br />iVi U* 1^/0 ■F/ggTvHmg <br />5. PROJECT PURPOSE (wl^ is this project nccdod • what boxfits wilJ it provide?) <br />S05/rriAfJHgO UAg/^\t=r________________ <br />6. a LTERN AT. VES (describe any other iltec or methods that could be used to achieve the purpose of your project while avoiding or <br />minimjojjg watn/wcUand iinoRcU. Attach additional ahacts, if needed. __ <br />7. DATES: Proposed start of activity; <br />(Tdena: V tny oompleiod work on ataiohsd drawing) <br />Pro|>osod completion; <br />8. (Aoach list If more) <br />9. PERaMITSH WE BEEN RECEIVED (R) OR APPLIED FOR (A) FROM:____ <br />-------coui>mr CITY_____mn poiiunoN control agency <br />DNR army corps of encr <br />I hereby Qolify the recipients of this fonn of the projeot proposed bercla usd ^ucst 1 be advUed of any permitt or.other determ matioos <br />cooccmictg ih*s [project that I must obodo. I undersuod that prooeediog work before ill rcquiicd auOiojiittioDS irt obtained Duy be <br />subject ^ Federal, State and/or local adt^inliuadv^ civU tad/or crimlnii pen^ts, <br />rfi/o2^ <br />SigWaMre of Pason PropoiingProicct or Agent (Muuikjr')Data <br />AU8 O5 20B '