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� � Permit# - `� �� <br /> Sandblanke�t Permit and Sand Source Exhibit-Form <br /> FAST 7RACK PEM�MI�' <br /> MINNEHAHA CREEK WATER�HED DISTRICT(MCWD) <br /> 182Q2 MINNETONKA BLVD. Ph: 952-471-059� <br /> DEEPHAVEN, MN 55391 Fax: 952-471-0682 ' <br /> �'���. � � ; � W <br /> , n 2Z reside at �� � � ��S cd �d ,� '� Q . � ��� C� <br /> (Propehy Owner) sc���l� (Aodress) (Gity) <br /> �`�l`��n��-�.,`, �il )_�ig -"��S�3. request approval to install a sandblanket on property described <br /> (Sl�ld,Zp) (Phane) r <br /> as 2�t t � C�a�o �o'�hE- �c� , located in ,�t �����,t�'��G._; �-Fhvl� `✓� <br /> (Strect addross) r � (Witliln tha Clty bouridarles) (Counly) <br /> �0 -t I�-23-�'l-OJ3 on {�'�iv�n.�.-tor��'� , � �� S <br /> (Property ID tk(PID#J� (Lake) (Bay) <br /> ❑I ha�e contracted with �'\��-�_ _ �- ���-�a����� ��^"e- � ��. <br /> (N;�mo of Company) (Streei address) <br /> , ( ) to install clean sand from the <br /> (Cily,SLaIB,Zp) (Phone) . <br /> fvllowing source , <br /> (Supplicr) (Address) (Cily,21p) <br /> ` � (Phone) �v��`�� <br /> ❑ I will install the sandblanket fronn the following source �� r'A ti^ 1��� �►'�oJ��''; <br /> (Suppller) <br /> (Address) � ,(Ciiy,S1ate,Zlp) � � � (Phone) '� <br /> 2 S�c.�.c�„tS <br /> IVIy shoreline is 2 � feat and the dimensions of the proposed sandbl2inket are: _����1�X � f—f�'''''_l <br /> � (lengln) �Y,W�ve�Gi� <br /> X � Sandblanket dimensions cannat exceed a length of 50' (or 50% of shoreline), <br /> (Depth) idth) <br /> a width of 10' a�d a depth oF 6„. If this project requires municlpal approval or review, please attach <br /> documentatlon of the munlcipal approval wlth this applicatfon. � <br /> I understand that rf this application is not completely filled out, o� if I fail to submit the required exhibits, the <br /> application is incor�plete and will be �eturned. It will not be reviewed.by MCWD staff until complete. By <br /> signing this application, I agree and understand that the District may enter the property at reasonable hours <br /> to conduct an inspection to determine whether the termS of the perinit are befng met. 1 further understand that <br /> if I violate the terms and conditians of the permit that is issued based upon this application, the District shall <br /> � eonduct a field inspectian�of the project pe� MCWD Rule J, provided with this application. I understand the <br /> Dfstriet will cha�ge fees to cover the actual costs of field inspections, including investigation of tho area <br /> affected by the work, analysis �of the work, including the services of legal counsel and angineers, and any <br /> subsequent rfng of the work. The District�s actual costs are deeme�d to begln accruing when the District <br /> i tice of lation to permittee. I have read and understand the MCWD Technical Guidelines for <br /> sandblan et <br /> lo � ._O�- <br /> ' roperty O er) - / � (Date) <br /> Subscribed and s orn t efor me on thls�day of C�tC►�� , 20Q� . <br /> � <br /> MARCIA JO WALLING�i�RO <br /> Notary P liC NQTARYPUBLIC-MINI�bDTA <br /> . My Commisslon Expires.lan.91.2012 <br /> Approved by: Date lo °l b <br /> z0iZ0'd ZO:bti LaOz-6Z-1�0 <br />