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COMBINED JOINT NOTIFICATION FORM -WATER RESOURCE APPLICATION app1 <br />Use this form to notify/apply to the Minnehaha Creek Watershed District (MCWD), their engineering consultants. the <br />DNR, and the Hennepin Conservation District of a proposed water/wetland project or work which may fall within their <br />jurisdiction. These agencies should advise you of their jurisdiction or permit requirements within 10 days. Fill out this <br />form completely and mail a copy, with plan, maps, etc ... to the MCWD, 18202 Minnetonka Blvd .• Deephaven, MN 55391 <br />Keep a copy for your records. <br />YOU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br />l. Applicant's Name (Last, First, M.I.) <br />Ct+-0 F 0f'CJl\c, -l/600 <br />2. Location of proposed project (Attach drawing w/directions to site): <br />COUNTY QTR SECTION(s) SECTI0N(s) T0WNSHIP(s) RANGE(s) Lot, Block, Subdivision <br />/--leril\eplf\ 2-3 /17 N Zs W <br />PROJECT ADDRESS: CITY: 0 ro A. cJ <br />3. LENGTH OF SHORE AFFECTED (in feet): VOLUME OF FILL OR EXCAVATION (Cubic yards): /I. Z.G t. '( .r.-; ,,, <br />AREA FILLED OR EXCAVATED IS Acres, OR Square Feet. Flood-() ltif"'-,,.;,r I'! <br />1 a.rt R.ri.. +-We.. +Lr,..;-., s +-' <br />0 STORMWATERMANAGEMENTPLAN ~FLOODPLAIN ALTERATION <br />□SHORELINE IMPROVEMENT <br />a.ORIPRAP <br />b.OSANDBLANKET <br />c,ORETAINING WALL <br />□STORM SEWER OUTFALLS <br />□ICE RIDGE REMOVAL <br />□BRIDGE & CUL VERT CROSSINGS <br />CZ} WETLAND ALTERATION <br />0 EXCAVATION (DREDGING) <br />a.D WILDLlFE <br />b.O NAVIGATION <br />c.O BIOENGINEERING <br />OTHER(DESCRIBE) ______________________________ _ <br />4a. APPLICANT'S REPRESENTATIVE: (Licensed Contractor, Engineer, etc ... ) Include name, address & phone number. <br />5f. Po..u I <br />5. PROJECT PURPOSE (why is this project needed -what benefits will it provide?) <br />6. ALTERNATIVES (describe any other sites or methods that could be used to achieve the purpose of your project while avoiding or <br />minimizing water/wetland impacts. Attach additional sheets, if needed. <br />7. DATES: Proposed start of activity: Proposed completion: <br />(Identify any completed work on attached drawing) <br />8. NAMES & DRESSES OF ADJOINING PROPERTY OWNERS (Attach list if more) e... f-f-.-e, {,,,, ~ . <br />9. PERMITS HA VE BEEN RECEIVED (R) OR APPLIED FOR (A) FROM: __ DNR __ ARMY CORPS OF ENGR <br />__ COUNTY __ CITY __ MN POLLUTION CONTROL AGENCY <br />I hereby notify the recipients of this form of the project proposed herein and request I be advised of any permits or other determinations <br />concerning this project that I must obtain. I understand that proceeding with work before all required authorizations are obtained may be <br />subject to Federal, State and/or local administrative, civil and/or criminal penalties. <br />Si nature of Person Pro osing Project or Agent Date