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P1 .~ANENT NON-MULTIPLE DOCK L .ENSE APPLICATION
<br />Lake Minnetonka Conservation District
<br />18338 Minnetonka Blvd.
<br />Deephaven, MN 55391
<br />Phone (952) 745-0789
<br />LMCD Receipt# / ') S 1·~
<br />In accordance with Scc.2.06 of the LMCD Code, the following application for a permanent Dock License shall be
<br />completed in all respects and submitted to the District office. No person may locate, construct, install or maintain a
<br />new permanent dock on the lake without first securing a license providing that no such license shall be required of
<br />docks requiring a license under sec 2.03 of the LMCD Code. A new license is required whenever the size, type,
<br />location, or configuration of the dock is changed. No new license is required for repair or replacement of a previously
<br />permitted dock where such repair or replacement does not alter the size, type, location, or configuration of the dock.
<br />Because this form is to be copied, please use black ink or type.
<br />The person completing this form is the authorized agent or property owner (circle one).
<br />Applicant: _ _,J'-'t1_,_;'-'-; J_,_117~t_,_,_ft..,_1J=7,,t'-"·-a::::..' _,fh:......,.· ='J/-'-f""""a'-'· 6=1<..:::::c:~1,.""'0"-'f;'--'f'c"'--;/ge:µ..,.liL:;?j-:,,.----------
<br />Address: ___ :.=5c..:l:....;JV"e:../i_-l-'l,"'-'1J'.'--"f..,.,,S,...f'-. _____._fp""'•'-'1'--'<i'-'=e.'--"".-:..'S,,__,n'..L; -_,_e.lC.P_,_c_· -----------------
<br />City, State, Zip: _ _,CX=· "'-'-'--G_._e_,__,/,5"--',,__· ·=uL..r-_---'-'(}'-'7..!...lv=--1---"'~:....L'J_..,~'--"'3,c__:_/ ______________ _
<br />Phone: _ __,__9-"-· "">.c:c.2_-_._:(_,_7_d.__, _---'--9__,._L/-"5=--...:....t/_· ___ Fax: '3 -S-Z-'-/7 '-/-&-7 I 2.-
<br />Property Owner (if different from applicant): ----=-M..,_,t....r;"'/_._·?_,_h...::c,_,_,?lt=S _________ _
<br />/;/;0-{/t"r,,gadd,res:;. 3<:51() Yc:d:. Av'€';.r,li.t..,::XL...-ri-J /uinrwetpo/11 MN 55410
<br />Job Address SSO B/g Island Otcno /nN
<br />City, State, Zip: ___________________________ _
<br />Phone: ----'w::....i __ / 2_-_c,__,yz=(,_-·.....;Q==-;=(p_7'--'-7 ____ Fax: ______________ _
<br />Documents listed below are r~quir~d; and must accompany this application: . ,i . ,-,., , l □Locator Map IV/-4 · B: S :6kh-(,\ □ Scaled drawing of docks on abutting properties i;~~~r~t c.,
<br />□County Plat Map □Proposed facility site plan
<br />□Certified Land Survey, Legal Description □Existing facility site plan ~o/1 ;"' Ooc,k
<br />Absence of significant requested data, could result in a processing delay.
<br />1. Type of facility {>O private
<br />( ) commercial
<br />( ) multiple dwelling
<br />() other ( explain)
<br />2. Intended use of dock facility ___ 7-/J.t2'-'-Y✓...,_1-"--l/tl:.:..:.._;fe:::._-"--'li"-'J4"'"1i,...,.C'""-r"'""i,_J;r,~tfff'-'/..~I'--'-'-JJ=66"""''/_,__v1.:...il:..:'IC(.,_·· ____ _
<br />3. Abutting property owners at the lakeshore:
<br />NorthorWest Thomas L4tJ/?1i,q frlc t5ivi /5/01Jrl Oron4 M/V , la.me andaddress J
<br />South or East tzabod' -../4'bbaur 5¼ !3ig /sJa11d CJ/7Jou !UN
<br />name and address
<br />~/2-?la 9-1130
<br />GIZ-599'-2<.?3f/
<br />Other affected parties _______________________ _
<br />name and address
<br />I of2
<br />JAN -7 2005
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