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<br />COMBINED JOINT NOTIFICATION FORl\1 -WATER RESOURCE APPLICATION appl ·
<br />Use this form to notify/apply to the Minnehaha Creek Watershed District (MC':'/D), their engi~cering consult_an~s, the.
<br />DNR, and the Hertnepin Conservation District of a proposed waterh•rntland pro.1ect or work wluch may fall ,~1tlun th~1r
<br />jurisdictictn.:. These agencies should advise you of their jurisdiction or pennit requirements within 10 days. Fill out_ this
<br />form completely mail a copy, with plan, maps, etc ... the MCWD, Gray freshwater Center, Navarre, 2500 Shadywood
<br />'Pu;jlt'1 1 14111¥ 'a7 1 B,.._l1l«1t; MN Uiil, Keep a a;opy_for )'~Ur rci;:mds, YOU MUST 0BTAlN A.LL REQUIRED
<br />AUTI-IORIZA"MONS BEPOM BEOINNINOWORK. · . . ··
<br />L Applicant's Name (Last, First, M.L)
<br />r 1u #li1J'r/µ
<br />Address (Street. RFD, Box#, City, State, Zip)
<br />· 37Sa E' ~,,;, o t? ;,./
<br />2. Location of proposed project (Attach drawing w/directions to site): ____ ·
<br />COUNTY QTR SECTION(s) SECTrON(s) TOWNSHIP(s) RANGE(s) Lot, Block, Subaivisiori'""~--•--
<br />/llf vµfnµ ...vlv 5 1 I 7 2..3 2 1 6'uA.C€,it.J d;1't'J1,N·
<br />PROJECT ADDRESS: ]7 5 () '/ /I.ii 6 .tf.,.,:J JI} .fN'4,.vtJ ,iJl 71/J,.._.,
<br />3. LENGTH OF SHORE AFFECTED (in feet):,Vt?Vf" VOLUNIE OF FQ:.LOR EXCAVATION (Cubic yards);
<br />AREA FILLED OR EXCAVATED IS Acres, OR Square Feet.
<br />4. TYPE OF PERlviIT BEING APPLIED FOR: (Check all that apply): ,.
<br />~T0RMWA TER MANAGEMENT PLAN O FLOODPLAIN ALTERATION
<br />□SHORELINE IlVlPROVEl½ENT
<br />a. ORIPBAP, '
<br />b,OSANDBLANKET
<br />c,ORET AIN1NG WALL
<br />OST0RM SEWER OUTFALLS
<br />□rcE RIDGE REMOVAL
<br />□BRIDGE & CUL VERT CROSSINGS
<br />0 WETI.AND AL TERA TI0N
<br />0 EXCAVATION (DREDGING)
<br />a.□ WILDLIFE
<br />b.□ NAVIGATION.
<br />c.Q BIOENGINEERING
<br />0TIIER (DESCRIBE) ___ ~--------------~-------~--~-
<br />4a, AP?J.JCAl'lT'S REPRESENTATIVE: (Licertsed Contracto Enginee etc, .. ) Include name, address & phone number.
<br />. ,11,J,tk. 61<.tJµ,lft/l.C, {C'tJ;;",C'/v? C.1.PJ/,!~,ec ,/,;.v,:-_
<br />3/.? l 7..1.H J-<A.C K A J/(.,vw ~ fJp',;._jAk.,"€ µ f 5 J 5' ('
<br />5. PROJECT PURPOSE (why is this project needed -what benefits will lt provide?)
<br />//vliJJ)./t:: 1'W ( /,(,1P(.I. l'r 7'.{) C.J.('1'1t c).Ut _.v,LL.., t t1-r "J'"',!l C"O /4//7/21
<br />-rll( t:)µ6 €':X1.M1.Jtt pdt'(Jf'.
<br />6. ALTERNATIVES (describe any other sites or methods that could be sued to achieve the purpose of your project whjle avoiding
<br />or minimizing water/wetland impacts. Attach additional sheets, if needed.
<br />,,(../ "o oJ tf· '"'""" / ,,( A. 6 d f i/4/ r: / JL( / A ( 7 F LJ
<br />7: DATES: Proposed·stan of activityM.c'~~ f.U,ot,.. fF.,, / 1 'IF Proposed completion:
<br />. (Identify any completed work on a~a~efrala~n{)""-' ,1. dffn.:f 'i:I~.
<br />8, NA11ES & ADDRESSED OF ADJOINJNG PROPERTY Q\VNERS (Attach list if more)
<br />Jr-:'f ✓mt'N(./ (;.-U"r
<br />c.c.-'l.;vrF,<. / 11,/' ,:l'A tVNC.,,...i
<br />('1'r /,f .IPJ.t.J ,t, AW/(,,.r i)i',-'
<br />9, PERWTS HA VE BEEN RECEIVED (R) OR APPLIED FOR (A) FROM; DNR ARiv1Y CORPS OF ENGR
<br />__ COUNTY 6 CITY __ :tvrN POLLUTION CONTROL AGENCY --
<br />-,: :,, :,, ',,(t>J.,/, (., P. r "~ 17. o ,c..,:,1(./',1.' c.r. "' /.:?,-<.,". ..
<br />I hereby notify the recipients of this fonn of the project proposed herein and request I be advised of any permits or olher
<br />dete · · o ~eming this project that l must obtain, I understand that proceeding witli work before all required authorizations
<br />· ed ubject to Federal, State and/or local administrative, civil and/or criminal penalties
<br />Daµ;rtf.
<br />----.,
<br />rnTHL F'. 03
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