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I <br />::r <br />* ■ <br />• • <br />0 <br />• • <br />, • •• •I. <br />' COMBINED JOINT NOtTFICATION FORM - WATER RESOURCE APPLICATION ^ppi <br />U<c this formTo notify/apply to the Minnehaha Creek Watershed District (MCWD), their engineering consultants, the <br />DNR, and the Hennepin Cbnservation District of a proposed water/V-etland project or work which may fall within their <br />jurisdiction.. These agencies should advise you of their jurisdiction or permit requirements \yithin 10 days. Fill out this <br />form completely rr.ail a copy, with plan, maps, etc... the MCWD, Gray Freshwater Center, Navarre, 2500 Shady'wood <br />Road, Suite 37, Excelsior, MN 55331. Keep a espy for your records. YOU MUST OBTAIN ALL REQUIRED <br />AUTHORIZATIONS BEFORE BEGINNING WORK. _______________________________________________ <br />2 Location of proposed project (Attach drawing w/directions to site): <br />COUNTY . QTRSECTION(s) SECTION(s) TOWNSHIP(s) PANGE(s) Lol Block, Subdivision <br />Se ........ ^ ^''7 '13 i.'J/Jsf <br />PROJECT ADDRESS: AfO. .'i'IDO FoX. *5TfiBET — OI2DA(0 /CT a , f.u /3U <br />3. LENGTH OF SHORE/U-FECTED (in feet): VOLUME OF FELL OR EXCAVATION (Cubic yards), q <br />AREA F1LLEI><^ EXCAVATED IS O Acres. OR Square Feet. <br />4. TYPE OF PERMIT BEING APPLIED FOR: (Check all that apply): <br />• * • <br />^STORMWATER MANAGEMENT PLAN □ aOODPLAIN ALTERATION □ WETLAND ALTERATION <br />□SHORELINE IMPROVEMENT QSTORM SEWER OUTFALLS □ EXCAVATION (DREDGING) <br />a.GRIPRAP . 3.G WILDLIFE <br />b-GSANDBLANKET GlCE RIDGE REMOVAL b.Q NAVIGATION <br />c.GRETAINING WALL c □ BIOENGINEERING <br />. . . QBRIDGE & CULVERT CROSSINGS . <br />OTHER-fOESCRlBE) • .......... ' ............ ‘ <br />• <br />4a. APPLICANT’S REPRESENTATIVE: (Licensed Contractor. Engineer, etc...) Include name, address & phone number . <br />CCfPjf-' t //A/C. ri s «-ner <br />6. ALTERNATINES (describe .any other sites or methods that could be sued to achieve the purpose of your project while avoiding <br />or minimizing watcr/wctland impacts. Attach additional sheets, if needed . , f -r/» a r r a »a . njtA-ri <br />AJO cuirCAy^S AA-C , C otS AA( /AAC^f Ta <br />tJOU'jd a ^^'t oA€rUAyAj. <br />7. DATES: Proposed start of activity: . Sfi/i/AjlS- ^~7- Proposed completion. J'AfMHf/t. "^ 7 <br />'■ (Identify any.completed.work oad’ltachcd.drawing) . . <br />8 NAMES & ADDRESSED OF AD.IOINING PROPERTY OWNERS (Attach list if more) <br />A-TTA<CU^G U-^ <br />. . • . . . » . . <br />Q PFPMIT«^ have BEEN RECEIVED (R) OR APPLIED FOR (A) FROM: DNR ARNY CORPS OF ENGR <br />COUNTY- >d^QET{ MN POLLUTION CONTROL AGENCY <br />• <br />• <br />i <br />1. <br />i • <br />t • <br />I nouiy uic una aviiu v* --------— w. —^ .......---------------- <br />detenninations coric.erriipg.Uiis project that I must obtain. I understand that proceeding with work before all required autnorizations <br />arc obtained may be subject to Federal, State and/or local administrative, civil and/or criminal penalties. <br />/rr-nsRiyg-y <br />^^SnjUure^ Person ft-opo Project or Agent AFPu XTt Date <br />• • • •