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• • ••** <br />(I <br />J <br />1 <br />I <br />1 <br />a.*• •• •f %I. <br />' COMBINED JOINT NOTIFICATION FORM -'WATER RESOURCE APPLICATION ippi' <br />It* • r- <br />• t«< I • V •.V » <br />Use this form to notify/apply to the Minnehaha Creek Watershed District (MCWD), their engineering consul^ts, the <br />DNR, tind the Hennftpin Cbnservation District of a proposed water/wetland project jr work which may fall'within their <br />jurisdjLqtion.^ Th'esc agencigs„should advise you of Aeir 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 Shad>'wood <br />Road, Suite 37, ExCclslor, MN 55331. Keep a copy for your records. YOU MUST OBTAIN ALL REQUIRED <br />AUTHORIZATIONS BEFORE BEGINNING WORK. <br />1. Applicant’s Naihe (L3st,‘First, M.I.) <br />1^. <br />Phone No. <br />Address (SU’ec't, RFD, Bo.v #, City,'State', Zip) ‘ <br />Rsy lOfJG' tf\N 5^^ <br />Ii <br />i <br />1 <br />^ • I <br />2. Location of proposed project (Attach drawing w/directions to site): <br />COUNTY - QTR SECTION(s) SECTION(s) TOWNSHIP(s) RANGE(s) _ Lot, Block, Subdivision .se........ s ■ /n <br />PROJECT ADDRESS: 4»/P. y 4cJ yJZ/ <br />3. LENGTH OF SHORE AFFECTED (in feet): VOLUME OF FILL OR EXCAVATION (Cubic yards); Z <br />AREA FILLED-OR EXCAVATED IS O Acres, OR Square Feet. • ^ <br />I <br />4. TYPE OF PERMIT BEING APPLIED FOR: (Check all that apply): <br />)^STORMWATER MANAGEMENT PLAN □ FLOODPLAIN i^XTERATION <br />□STORM SEWER OUTFALLS <br />□ICE RIDGE REMOVAL <br />□SHORELINE IMPROVEMENT <br />a. QRIPRAP <br />b. ^SANDBLANKET <br />c. ORETAINING WALL <br />OTHERXDESCRIBE) * <br />• • • <br />• ••*•• M • • • <br />□BRIDGE & CULVERT CROSSINGS . <br />□ WETLAND ALTERATION <br />□ EXCAVATION (DREDGING) <br />a n WILDLIFE <br />b. ^ NAVIGATION <br />c. ^ BIOENGINEERING <br />4a. APPLICANT’S REPRESENTATIVE: (Licensed Contractor, Engineer, etc...) Include name, address & phone number. . <br />jt ./AyQ, _ ___ <br />yifZ TAM a MCK ^-,2 1^^. yA 5>V\G»O^VlQ^ ^ <br />i1 <br />I <br />! <br />/i. I^OJECT PU^OSE (why is this^rojcct ne«kd - what benefUs will it provide?)^' ^ O ^ 5^^ <br />- » <br />6. ALTERNATIONS (describe .any other sites or methods that could be sued to achieve the purpose of your project while avoiding <br />or minimizing water/wctland impacts. Attach additional sheets, if needed. <br />Aja UJfTLAy/S Afi-C , COrS AA.( £4ACr( TC <br />\ <br />7. DATES; Proposed start of acljvity: ! ‘f~7. <br />(Identify any.completed.workon.4 ’|tache ‘d.drawing) , <br />Proposed completion: <br />.'f* *>• <br />8. NAMES &. ADDRESSED OF ADJOINING PROPERTY OWNERS (Attach list if more) <br />A-TTAC^a^Q U^T________L • <br />9. PERMITS HAVE BEEN RECEIVED (R) OR APPLIED FOR (A) FRO.M;_____DNR <br />COUNTY.. >^(^)GITY _____MN POLLUTION CONTROL AGENCY <br />ARVY CORPS OF ENGR <br />I hcreby notify the redpients of this form of the project proposed herein and request 1 be advised of any permits or other <br />determinations cprtc.emipg.this project that I must obtai:i. I understand that proceeding with work before all required authorizations <br />are obtained may be subject to Federal, State and/or local administrative, civil and/or criminal penalties. <br />Cnw-5::^ & WJf^*sr=>N/Arrri&g.Wgy VLj\% <br />•oject or Agent^ »Af Aj CA V /Sisaaiure^ Person Proposing Project or A gent Date <br />• « * *6ioy 3M ) — <br />• *♦ #• •• •