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COMBINED JOINT NOTIFICATION FORM— WATER RESOUItCE APPLIC�^A�ION a��n� <br /> !�-a�- �1 fk� �l�C <br /> Use tl�is forin to notify/apply to the Minnehaha Creek Watershed Disti•ict (MCWD),their engineet-ing consultants,the <br /> DNR, and the Hennepin Conservation District of a proposed water/wetlaiid project or work�Wh�ich may fa11 wifllin tlleir <br /> jurisdiction. These agencies should advise you of their j�urisdiction or pei-init requirements withui 10 days. Fill out this <br /> form completely and mail a copy, with p1an,maps, etc... to the MCWD, Gray Freshwater Center,Navarre, 2500 <br /> Shadywood Road, Suite 37, EYcelsior, MN 55331. Keep a copy for your records. YOU MUST OBTAIN ALL <br /> REQUTRED AUTHORIZATIONS BEFORE BEGI'NNING WORK. <br /> l. AUplicanYs Name(Last,�Pirst,M.1.) Plioue No. <br /> �, � ' a ��Z .• _-�-�1- 3�-t`1 I <br /> Address(Street,RFD, Box#,City,State,Zip) <br /> 1 ^_. <br /> �� �,� � `J� <br /> 2. Locatioii of pr•oposeci project{Attaeli drawing�v/directio�is to site): t <br /> COUNTY QTR SECTION(s) SECTION(s) TOWNSH[P(s) RANGE(s) Lot,Block, SuUdivisiou <br /> �'�"�V�,Y�L'-�`.r� /-c,-`-� t3�I�I,, C.Es��--�`> a��.c�y�--�p `���!l�ar,c� Z--c��lc�- VY�'���.. <br /> PROJECT ADDRESS: Z5 y , - `�� CITY: �� <br /> 3. LENGTI-I OF SIIORE AFFECTED(in feet): VOLUME OF FILL OR EXCAVATION(CuUic yards): (�f c��— <br /> AREA FILLED OR EXCAVATED IS Acres,OR Squarc Fect. �cr��..s �« "� :�--�` <br /> �eX'�y h�s tS—C ' c�_`<' 'l �_t�` ��..�,�� c3��r�vv c<<_. <br /> 4. TYPE OF PERMIT BEING:�PPLIED FOR: (Check all that apply): <br /> ❑ STORMWATER MANAGEMENT PLAN ❑ELOODPLAIN ALTERATION ❑WETLAND ALTER��T[ON <br /> ❑SI-iORELINE IMPROVEMENT ❑STORM SEI�EROUTF�II:LS ❑ EXCAVATION(DREDGING} <br /> a.❑RIPRAP a.�WILDLIFE <br /> b.❑SANDBLANKET ❑ICE RIDGE REMOVAL U.❑NAVIGATION <br /> c.❑RETAINING Wr�l:L c.�BIOENGINEERiNG <br /> ❑BR[DGE&CULVERT CROSSINGS <br /> OTEIER(DESCRIBE) ��-O`�iGltti.i C'�Y\1'CY'�L;P_._. <br /> 4�. APPLICANT'S REPRESENTATIVE: (Liceused Coutractor,Eujiueer,etc...) Include nzme,address&phone nuniber. �'Z� <br /> `� l�lil � l:�f'T"�'�^ `' � Z-� � � �� (J�. � � � c;� � ��D=-Elc. <br /> �. PROJECT PURPOSE(wl�y is this project ncecied-what benefits will it provide'?) <br /> � <br /> ��uv ���� �('_EE� S1(�-G � , � ���1. <br /> C.ALTERNATTVES(describe any other sites or methods that could be u,ed to achieve the ptirpose of your project�vhile avoiding or <br /> minimizing�water/�r�etland iii��pacCs. Attacl�additional sheets,i�Fneeded. <br /> 7. D��TES: Proposed start ot�activi�y: � Z3\�'J�- Proposc�l complction: �un.e� �-��j <br /> (ldcntify any co�uplctccl�vork on attached dra�ving) <br /> g. NAMES 8z ADDRESSES OF ADJOINING f'ROPERTY OWNERS(Att�ch list if inorej <br /> i�5 G:r�-�cc����a; 5-t�.�.��.�Sc��r� � �c�� �—�r��n,N4 ,��,�� ��� ' �S3 <br /> �J �] v ` J✓� -� .'l j! <br /> 9. PERM[TS�tAVE B�EN RECEIVED (R)OR A PL[GD FOR(A)FRUM: DNR ARMY CORPS OF ENUR <br /> COUNTY�Z�CITY MN POLLUTION CONTROL ACrENCY <br /> I l�ereby notify the recipie�its of this forin of the project proposed herei�l and requcst 1 bc advised of auy permits or other deterinitlations <br /> concer�ling this project that L must obtain. [understa�id tliat proceediug witli���ork'befoi•e aL1 reqaired authorizations are obtained may be <br /> subject to Federal, tate an�,�or local ad�iwlistr•ative,eivil and/or cri�iiinal penalties. <br /> �r �►i ?,� G" <br /> Sienatur� of Person�Fro osing Project or A ent Date <br />