|
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 />
|