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W-221 Rev. 74 STATE OF MINNESOTA DEPARTMENT of NATURAL RESOURCES Division of Waters, Soils and Minerals NOTIFICATION OF PERMIT APPLICATION INSTRUCTIONS FOR THE APPLICANT Minnesota Statutes, Section 105.44, Subdivision 1, requires you to supply a complete copy and all supporting data of your water permit application to the following: A) The chief executive officer of the city or township within which the project is located. B) The secretary of the Board of Managers of the watershed district, if any, within which your project is located or which your project may affect. You MUST certify having served the complete application on the above in the box on the back sideo7-the application form W-54. IN ADDITION, if your project is NOT located in a city, a complete copy and all supporting data of the application should be submitted to the Administrator of the Shoreland Manage- ment Program for the affected county. Complete this form for each notice served on a local government official. SECTION I (TO BE COMPLETED BY APPLICANT) TO: A) Chi f executive officer of the (check) city, [Q township of e�ryNO (print or type n=e) y B) Secretary of the board of managers of the ,�'l1#ifC 4 k6 watershed district. (print or type n=e) C) Administrator of the shoreland management program of 4WIfe lil county. (print or type ncaw, FROM: IA 7;9i1wovl 41 k� �r� %K 577-Y/ Date: k/ l0 19 � (print or type naddress of applicant) INSTRUCTIONS FOR THE LOCAL GOVERNMENT This report from provides you an opportunity to submit input to the Department of :Natural Resources to assist in deciding whether to grant, modify, or deny the requested permit. It is NOT absolutely necessary for local agencies to officially approve or disapprove the project or make any recommendation, although this may be done if desired. It is requested that local agencies indicate the following, as applicable: A. The relationship of the proposed project to local plans for the affected water and related land. B. The relationship of the project to local land use controls including flood plain and/or shoreland regulations. (continued on reverse side)