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V •—• . • <br />1 <br />' COMBINED JOINT NOTIFICATION FORM - WATER RESOURCE APPLICATION appi^ * *«l • 0^• /.1’Use this form to notify/apply to tlie Minnehaha Creek Watershed District (MCWD), their engineering consultants, the DNR, aind the Hennepin Conservation District of a proposed water/wetland project or work which may fall wiihin their jurisdjiqtion'y The§c agencigs should advise you of their Jurisdiction or permit requirements within 10 days. Fill out this <br />form completely mail a copy, with plan, maps, etc... the MCWD, Gray Freshwater Center, Navarre, 2500 Shady^vood <br />Road, Sujtc 37, Excfelslor, MN 55331. Keep a copy for your records. YOU MUST OBTAIN ALL REQUIRED <br />AUTHORIZATIONS BEFORE BEGINNING WORK. <br />II I. <br />1. Applicant’s Name (Ldsf,'First, M.I.) <br />Jll <br />Phone No. <br />Address (Street, RFD, Bo.v #, City,“ State', Zip) <br />6*0 R5 > <br />2. Location of proposed project (Attach drawing w/dircctions to site): <br />COUNTY ' . QTR SECTION(s) SECTION(s) TOWNSHIP(s) RANGE(s) _ Lot. Block. Subdivision <br />se............ S //y ^ /jsp <br />PROJECT ADDRESS: A^'O. .'3S.OQ roX. - OT^A/O A y AU /JZ / <br />ft • ^ V m m w a mhm mm mm. a m ^ * —. _ _ 3. LENGTH OF SHORE AFFECTED (in feel): VOLUME OF FILL OR EXCAVATION (Cubic yards): ^ <br />AREA FILLED;(W EXCAVATED IS O Acres, OR Square Feel. ' • ^ <br />4. TYPE OF PERMIT BEING APPLIED FOR: (Check all that apply): <br />^STORMWATER MANAGEMENT PLAN □ FLOODPLAIN ALTERATION ’ □ WETLAND ALTERATION <br />□STORM SEWER OUTFALLS□SHORELINE IMPROVEMENT <br />a. ^RIPRAP <br />b. ^SANDBLANKET <br />c. ^ RETAINING WALL <br />OTHERrtDESCRIBE) • <br />□ EXCAVATION (DREDGING) <br />a.^ WILDLIFE <br />□ICE RIDGE REMOVAL ' b.^ NAVIGATION <br />c.^ BIOENGINEERING <br />□BRIDGE & CULVERT CROSSINGS . <br />4a. APPLICANT S REPRESENTATIVE: (Licensed Contractor, Engineer, etc...) Include name, address & phone number <br />^ CAdA^^ffi-C y ,Ay<:. <br />A.M . A4^ SSAJ6 Y7 S-Y/•Ai <br />YiT.2 ‘ 7A/^AA^Ck ^ <br />/i. P^JECT PURPOSE (why U Ws^roject needed - what benefUs will it provide?) ^ ^ <br />^ lA/J /Aa A ^ AAA A S iTAA. <br />6. i^TER_NATI\^S (describe.any other sites or methods that could be sued ij achieve the purpose of your project while avoiding <br />or minimizing waterAvctland ir^acts. Anach additional sheets, if needed <br />AJO CafTLAA^AS Afi-C , COT'' AA( A a AC^( TO A^tdA^OAA^f <br />tJOCcjjJ 'iAAjTCfptkT x/i/Y hAC tcma ^a J’. ' ' <br />7. DATES: Proposed start of activity: ! ’ ? 7. ’* Proposed completion^ JZIMA ^ y ' <br />• (Identify any.completed.work on.4'(tachc'd.drawing) <br />8. NAMES & ADDRESSED OF ADJOINING PROPERTY OWNERS (Attach Irt if more) <br />ATTAoUg-n <br />‘9. PERMITS HAVE BEEN RECEIVED (R) OR APPLIED FOR (A) FROM;_____DNR <br />_____COUNTY >. xT(>1)G1TY _____ MN POLLUTION CONTROL AGENCY <br />ARMY CORPS OF ENGR <br />I hereby notify the recipients of this form of the project proposed herein and request I be advised of any permits or other <br />determinations coric.emipg.tjjis project that I must obtain. I understand that proceeding with work before all required authorizations <br />arc obtained may be subject to Federal, State and/or local administrative, civil and/or criminal penalties. <br />-ioviv (h win -st^n / <br />^ ’A-rTOgfVg.y T=c2»2.;. <br />Si^oature"^ Person Proposing Project or Agent' A f Pli CA V~T <br />~ •• (hn-J <br />\x/ig- /<T6 <br />Date