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. <br /> COiVIBI�i 1ED JOINT NOTIFICATION FORIVI-WATER RESOURCE APPLICA ION app� <br /> l�a�- �f� ,� <br /> Use this forcn to notify/apply to the Miimehaha Creek Watershed District (MCWD),their engineerin�consultants,the <br /> DNR, and the Hennepin Conservation District of a proposed water/wetlaud project or work wtrich may f111 within their <br /> jtu•isdiction. These agencies should advise you of their jurisdiction or pennit rec�uirements within 10 days. Fill out this <br /> furm completely and mail a copy, with plan, maps, etc... to the MCWD, Gray Freshwater Center,Navarre,2500 <br /> Shadywood Road, Suite 37, E�celsior, MN 55331. Keep a copy for your records. YOU MUST OBTAIN ALL <br /> REQUIRED AUTHOFZIZATIONS BEFORE BEGINNING WORK. <br /> 1.Applicant's Name(Last,First,M.I.) Phone No. <br /> �. � o �,Z �- -}-�1- 3�-1`� I <br /> Address(Street,RFD, Box#,City,State,Zipj <br /> ��= 5S <br /> 2. Locatio�i of proposed project(Attacli dra�ving w/directions to site): � <br /> COUNTY QTR SECTION(sj SECTION(s) TOWNSH[P(s) RANGE(s) Lot,Block, Subdivision <br /> 1����r�ee`,r� L-c�-1� �3�i y �J��s a�.cth-�, �ad�-��or,d Lo k.�e- Vv�.�-kq.. <br /> PROJECT ADDRESS: Z� � � � � `�c CITY: Gy� <br /> 3. LENGTH OF SIIORE AFFECTED(in fect): VOLUME OF FILL OR EXCAVATION(Ctibic yards): (�.�e lf�e_— <br /> AREA FILLED OR EXCAVATED IS Acres,OR Square Feet. 5�i�� c�v � .T►`! <br /> �r�y h���' cS�- ' e.�� c,�,`� a �,��..�c.�_. <br /> 4. TYPE OF PERMIT BEING APPLIED FOR: (Check all that apply): <br /> ❑ STORMWATER MANAGEMENT PLAN ❑FLOODPLAIN ALTERt1TION ❑WETLAND ALTERf1TION <br /> ❑SIIORELINE 1MPROVE�IENT ❑STORM SEWER OUTFALLS ❑ EXCAVATION(DREDGING) <br /> a.�RIPRAP a.❑WILDLIFE <br /> b.OSANDBLANKET ❑ICE RIDGE REMOVAL b.0 NAVIGATION <br /> c.❑RETAINING WAL.L c.❑ BIOENGINEEfZING <br /> ❑BRIDGE&CULVERT CROSSINGS <br /> OTf�ER(DESCRIBE) �(�OSi 7V"�i C' �'���C'_.C�._ <br /> 4a. APPLICANT'S REPRESENTATIVE:(Liceused Coutractor,Eii�itieer,etc...) Include iiame,address&phone number. C���_ <br /> � t�l� �- �.��``��1� �' ' LI c� l�� c�. � � � ��f°-�1� <br /> 5.PROJECT PURPOSE(wl�y is this project neecled-what benefits will it provide?) <br /> ��1,� ��,C�('� �l \ � �\l. <br /> 6.ALTERNATIVES(describe any other sites or methods tllat could be u,ed to achievc tlle purpose oF your project�vl�ile avoiding or <br /> mi�limizine water/�cetland impacts. Attach additional sheets,if nceded. <br /> 7. DATES: Proposed start of activity: 4`l Z3\QZ Proposed completion: ��,�n.e17�3 <br /> (Identify any completed�vork on attached dra�ving) <br /> 3. NAMES& ADDRESSES OF ADJOINING PROPERTY O�VNERS(Attach list if more) <br /> � a,z; s-��:N� � � , , ,AK -5� <br /> s� , � � t' s. <br /> 9. PERNIITS HAVE BEEN RECEIVED (R)OR A PL[ED FOR(A)FROIvi: DNR ARN1Y CORPS OF ENGR <br /> COUNTY�CITY N1N POLLUTION COMROL AGENCY <br /> 1 hereby notify the recipients of this form of the project proposed herein and request I be advised of auy permits or other det�nnivations <br /> concerning this project that I must obtain.I understand tliat proceediu�witli work before all required authorizations are obtained may be <br /> subject o Federal, tate aii or local administrative,civil and�`or criminal pe�ialties. <br /> �r � � O <br /> Si�natur of Person Pro osinU Project or ARent Date <br />