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MIIVIVEHAHA CREEK <br />WATERSHED DISTRICT <br />P.O. Bolt 347. Wayltata. Minnesota 55391 <br />See reverse side for Instructions <br />OWNERJ'V,155 1 ANSbl✓ra <br />ADDRESS. 5' Wya 11J P-4m <br />CITY: 0"00-IMN ZIP: _ <br />PHONEA73 <br />3. O Preliminary plat review <br />O Greding/Oralnege Plan <br />O Bridge. o Avert, or utllltles <br />O Rood Ptah Oeveiopment <br />O Use and appropriation of <br />Public Waters <br />#96 <br />PERMIT NUMBER <br />OATE RECEIVEO <br />AGENDA DATE <br />APPLICABLE REGULATIONS <br />Do not write above this line <br />Al Sc�crcv Y Rac� <br />2. APPLICANT: VG nYJ <br />ADDRESS: 3Z5 �//�► �L — <br />CITY;_! T MIV PNQNE: �S'01JSJ�i <br />SIGNATURE: —4� ' <br />Cl Shoreline Improvement or Rip -Rap <br />O Shoreline Setback Variance for <br />Property Improvement <br />Fill or excavation <br />(_I Permit Extension <br />O Other _ <br />Describe work and oblectives: P // e K CaV ?-h / 01f A4 <br />s1�4 . Fl od �,h eky7-1vm 131 = `';_i}v�r��e. low <br />41f opt soil -f a rhzI-ch-- 41U, `" 0 -fill JW444fo <br />44 X/0' d plzm— W43 r F10 al"VG _ick v=fiwL1 31'-6" <br />dots hod .e 'e�f--F1poid p)hjr1Cu+ 4b---ma+ch - s <br />_ar _ artz -raAL off <br />Project location: <br />D►'1N1�10 NIA% . <br />h 4-ro,) PsrtckaI"PS �� <br />Current status <br />with Olhe applicable <br />agencies: _Ft*jd, -_— <br />?PCM-—i---� J <br />6. Body of water affected: <br />Call 113-4221 fur assrslani a In curnplelln� Ihlt lurn� <br />