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. _,manent Non-Multiple Dock License Applicati,__ <br />4. Site lake frontage: raoO I feet; distance of dock into the lake: :5C I feet. <br />5. All setbacks for the dock use area have been observed ()() yes ( ) no. <br />6. All required permits, licenses and approvals have been obtained from the city in which the <br />permanent dock is located, and from the DNR: ( ) yes ( ) no <br />Explain: ____ _..c=------------------------ <br />7. Application Fee ........................................ $ 150.00 <br />After-the-fact application fee .................... $150.00 <br />Total Fee enclosed ......................................... $ __ _ <br />I certify that the infonnation provided herein and the attachments hereto are true and correct; I <br />understand that any license issued may be revoked by the District for violation of the LMCD <br />Code. I agree to reimburse the District for any legal, surveying, engineering, inspection, <br />maintenance or other expenses incurred by the District in excess of the am1>unt of the <br />ap~ation fee. I consent to pennitting officers and agents of the District to enter the premises <br />at all reasonable times to investigate and to detennine whether or not the Code of the District is <br />being complied with. <br />I a.gree to submit a certified, as-built survey upon completion of the docks. <br />~ ... ,~,-/-J-0[ <br />Ce \\'t,(~ \ ni\1-\Q,5-e:c <br />Title <br />Relationship to Owner <br />Return this application, attachments and fee to: <br />Lake Minnetonka Conservation District <br />18338 Minnetonka Blvd. <br />Deephaven,'MN 55391.:.3232 <br />Fax: (952) 745-9085 <br />2 of2 <br />JAN -7 2005