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ze'd �d101 <br /> •�v �-� � � - <br /> _ . <br /> � M�►� � 8 20�2 S��►N��RNII'��& S�l1�TD SOURCE �TT FORM' . <br /> MINNE�IHA CB.h'EK WAT�BSH�:D DISTgICT <br /> ----� � � � pBRMiT � <br /> ���.L�I�Y m �L..s_1�f.F�rzsiair,g ar.�r���- �A-,e�r,.a-�. I�,�o �,�'���..�;o�. n�,�, <br /> Property Owner . Addncaa City,Stafe,Zip „�S'��� <br /> �.5�-�17/-/0 3�. f��i✓� , or P1lD#� //7�3 - /Y--GY�,L� <br /> Phcnc Cbtttdy rCowemiup�Sed@on,@et�gc i��P�'��iy taa state�cnU <br /> own and ooaupy the above sit�,gte fsettily residenve and wish to ins�ll a s�dblanl�t on � <br /> � � C��� <br /> l�.�ae ae B.y . <br /> � I have cantracted with MinnEtonka Portaa►� Dr��'�.;i��g <br /> eo� @S • adA�esa <br /> ,�g to install ele�.n sand from the fol�owing sourc <br /> c�sy,srnt�,zip phone 4�49454 <br /> �dL�l• 1�i,<<�LLl��q�S,Or/ ����y� ,r`ItJi , � ,oC: <br /> suppliv eddrras phonc <br /> ❑ I will install the sandblank,et myself fsnm the following sourcc_ <br /> supputr <br /> � addrrs,a phonc <br /> IE thcs prvjecE requires municipal eppmval ar review,plea�e aitach documerttation af the mu�icipal appro <br /> with this appticatian. My shvreline is.,,��_fcet and the dimensions of the propos��d sand�lanket are: <br /> S'D (I.ength) x �1� (Widtl� x____�� (ikptla).Sartdblankct dimertsianx cane�ot exceed a <br /> lcngth of SO' (or 5046 oF shoreline),a vNidth of 10'�nd a depth of 6". � <br /> I unde�sE�and that if this appli�aEion is not compleEely ftlled out, or if I fail to subtnit the r�uired exhik <br /> the applic�ion is iaoomiplete and will be t�eturned..IE will rwE b� rcviewed by MCWD st�.ff until eompl� <br /> By s�g,cti.�g thia applioation, I agree and un�et�sland that tlie Diatriet may enter the pmperty at reasons <br /> hours to con�duct a.n ir�spection bo detertttitte whether the terms of the permit arc besng met� [ furt <br /> and�rstand•tl,�t if [ viiol,�te tlu terca,s•and conditi,ons oE a perniit tk�at is issu.ed based upon this applicati <br /> the District�tall`oonduct a field in�speetien of the projcet prr MCWD S.iuie f, prwided with this applicati <br /> [undcrstand=thc Disiric�will c�sargt fecs to eavex the actusi costs of feld inspections,inc.�udir�g investi,gal <br /> of thc srea affec6ad by the w�ork,analqsis af thc�work, includin,g th�serviae��i caoan�el and engine <br /> and any sub�uerf moniborir4$of the wurk. Thc Dist�rict's aeiva[oosts are dee to begin aecruing w: <br /> the DisErict �ssucs notice of the violakion to the permittee. [ hav� read ar�d understand thc MC1NQ Techn <br /> Guidelines for sandblsaket�. <br /> � w 8 1L�___��L�� . �+ , � V(J <br /> , � af�l ' � <br /> ! �StC <br /> Subseribed artd sworn to beforc me this �v day of �"� .200 02! <br /> . � <br /> ����� TERESA M. KES <br /> c�.G�� �' Notary Public <br /> 'i� Minnesata <br /> IVoEary Pu61ic � ..,.,-���:.,.' � �* : <br /> My Commissl'on Expires Jan..31, 20 5 � <br /> ,-��� l�lZ <br /> Approvcd and Accepted by Datc <br /> �. . . rr.t +-�',� .�. f - . <br /> z0iz0'd Z890 tiLbzti9 Q3HS�I�lti�1 �1�3�1� dHdH�NN I W Sb:L� z00Z-8z—JldW <br />