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JUPJ-15—'?��� 11� 1.� �'1I I•Jh•JEHHHH �_F•.'EEH: I�,IATE�"=�HEI! F�1�4�1�=�����'� F'.t r�: �i�
<br /> �d � � � �
<br /> COMBINF�J41NT NOTTF�C;ATION FQRM-WATER R�SQURCE AP�LYCATI�N appt
<br /> Usc tIus forcn to nptify/apply to the Minnehaha Creek Wat�r�;hed District (A�IC W f)j, their c;nginecring cunsuliants,tl�c
<br /> DNR, anc�the Hennepin Conscrvatinn District of 3 proposed w�ter/wetland pr�ject or work which may falI within th,ezr
<br /> jurisdiction, Tl�ese agencies should advisc yt�u of tlieir jiuisdiction or pertnii'rcquircme»ts wittun. 3.0 days. Fill out t}ris
<br /> forn�complctcly and maiI � copy,wrth plan,m�ps,eic... tv the MCWD,Cr3y Fresliwater C'entcr, Navarre,2500
<br /> Shariywood Road, Suite 37, Excelsior, MN 55331. Keep a c.opy for. yaur I�ecords. YOil IviUST 0�3TAIN ALL
<br /> RFQUIRLr7 AUTHC�RIZATIUNS BEF()RE BEGINNTNCT WC)RIL.
<br /> 1. AppGc,�Name(T,ast,First,M.I.) , Phonc No.
<br /> �v. �n ���- :,a. ,h CPra-��7i-ogo�
<br /> Addm.ss(Street,R�F/I'� �x#,City,State,'/_ipj 1 �p (/�
<br /> O� l.l 'Zl.T7i N �.71' !� I I-��rj--��r��� Q(�a�'
<br /> 2. Locarion of prnrosz8 projcct(Attach drawin�;w/dircetions to site):
<br /> �c7UNTY QTR SECTTON(s) SECTiON(c} T04VNSHIP(s) RANG�(s) i,ot,Block, Subdivisi��n
<br /> �" �'�[�:a�' SaK 1cb.1'�t�1�/fc
<br /> PRf�J�CT ADDRESS: .c CIT'Y:(�� 's �f,' ' � �Fk�.
<br /> 3. T,LNGTH Ur'SHURG APFECTED('in feet): �(� VOLZ)�MF UP I'ILL OR EXCAVATION(Cubic yards): $��i� �cr�vpfi�
<br /> ARGA FILLED C�Ft ExC,AVATED IS Acres,OR ��c�pSquarc Fcct.
<br /> 4' TYP�OF PERMI7 t3�rNC APPLIED FUR: (�.heck al]th:�c appIy�:
<br /> ❑STC?RMWATER MANAc;i'IvdNT PLAN []r[.,pOpPLA1N�1LT�RaTION ❑WCTLAl�'D ALTETtAT10N
<br /> L]SHORELINE IMPR()VT,?T�NT [�STORM SEWETt c:)UTPALLS ❑ �?LCAVATION(DR.F,pGING')
<br /> a.ORTPRA.I' a.�W�,llL1FE
<br /> b,�SANDBLANKF..T ❑ICL.RIDGE TtPMC]VAT. b.0 I`TAVICiATIUN
<br /> c• R�TAIIVING W�LL c.�}3IU�NGINEERINCr
<br /> . ❑BRIUCi�LE C.[}LVERT CRUSSINC;S
<br /> UTH�R.(.p�SCRIBP.) e
<br /> 4a. A.PPLICANT'S REpRESENTATTV'C;;(Liccnscd Contra�tor,�n��ine:cr,ctc.._j Tnclude n�unc,address 8:phone number.
<br /> � n rrn � �w�. !�i�7 ��,� 5�. �!��k ^�.�'' �s�ti� �r a- 4�?r-�5�03
<br /> 5.T�R.UJLCT PURPOSE(why is This prctijr.ct needed-w}�at ben�fits will it prqvide?j
<br /> �/Y�"�e�d'1�1�"�(/F- �S�"3 �Tr��G'1�+�'t- � �v��l��.�f //r G l�f�/ ✓uQJ'��r-r.rFi k( c.s'�c�t�'9�'L.
<br /> 6.ALTERNATI VGS(dcscribc any other sites ur mrthods that could be used to achieve tl7e purppsc of your pmjer:t whilc avoiding or
<br /> minimizing water�wetland impacts. :�ttach addi�ir.m�l shccts,if needed.
<br /> /l��_
<br /> 7.DATES� Pmpased start of activiry: f �� �OtlO Proposcd completi��n; ,�ti� ��j
<br /> (Idcnrifv an cam )eted work on attached drawin.g)
<br /> 8.�AME9&ADD�SES OF ADJ(�. G PROPERTY OWNF:RS(Attach iist if mn��e)
<br /> '7e�►, �--/i'1�,�� ',.t� G�5 �n s.�,o�.�<
<br /> n G �. .,
<br /> 9. PERMITS HAVE AE�:N KGCLIVED (R)()R,4F�Pi,ll;D FOR(A)FROM; DIvR AAMY CORPS OF ENC;R
<br /> cotn�r�_.,��.1TY MN PULLl17'IUN CONTROL AG�NC.}'
<br /> I hcreby nutify the rccipicnts of this furrta Of�the projcci pro��u5ed herein�md requcst I be.advised of any pem�its or pcher detcrminarions
<br /> cpncerning this project that i must obtxin.I undecstand tht11'procccding with work beforc all rcquired authC�rizatiuns arc obtained m7y be
<br /> subjec t 'e ,Statc and/or Iocal administrntivc,civil and/qr Criminal penalties.
<br /> Si a e o erson oposin Pro'cct or A ent Date � � u�
<br /> TCiTHL F'.Gr�
<br />
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