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E� On <br />�riD 0 <br />MINNEHAHA CREEK <br />WATERSHED DISTRICT <br />P.O. Box 387, Wayzata, Minnesota 55391 <br />See reverse side for Instructions <br />1. OWNER: LT--',f",qe T . <br />ADDRESS: I9&-. /�/l�llldCSS__Plt.r <br />CITY: ZIP: sr-3-V <br />PHONE: <br />3. ❑ Preliminary plat review <br />❑ Grading/Drainage Plan <br />❑ Bridge, culvert, or utilities <br />❑ Flood Plain Development <br />❑ Use and appropriation of <br />Public Waters <br />PERMIT NUMBER <br />DATE RECEIVED <br />AGENDA DATE <br />APPLICABLE REGULATIONS <br />Do not write above this -line <br />2. APPLICANT: —___- <br />ADDRESS: <br />CITY: PHONE: <br />SIGNATURE:r�);g <br />la Shoreline Improvement or Rip -Rap <br />❑ Shoreline Setback Variance for <br />Property Improvement <br />❑ Fill or excavation <br />❑ Permit Exten+lon <br />❑ Other _ <br />Describe work and objectives: A2#w1l, &._0� AK00 av- ,e?4Lv/iLt &eur-_ <br />L✓L �.__Oin '& L . - � re[ /tee Pia 'rZ K7,V V 6a ►d E9-wt AS rt e'214 O 01V .fh/&/ .. <br />4. Project location: -e4 l' 4 OP wr *0_FA6&"rX1 jVvT Ote <br />5. Current status with other applicable agencies: LvPwJ OF Tir..t <br />6. Body of water affected: .�4�orc mi yNe-7"yW -4 _ <br />Call 473-4224 for assistance in completing this form. <br />