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Permanent Non-Multiple Dock License Application <br /> 4. Site lake frontage: /E:y.l�� feet; distance of docic into the lake: �z � feet. <br /> 5. All setbacks for the dock use area have been observed O yes (�Zo. <br /> 6. All required permits, licenses and approvals have been obtained froin t11e city in which the <br /> permanent dock is located, and from the DNR O yes (.�iio <br /> EX]�11111: �G�izs" i i/� fJ i-�%'nt�4.��� �'/%Gr� /�-/�/,�i�C�ic.rt��' o�ir�c j i C'/1 <br /> 7. Application Fee........................................ $150.00 <br /> After-the-fact application fee....................$150.00 <br /> Total Fee enclosed.........................................$ 3c�o `-=� <br /> I certify that the infonnation provided herein and the attachments hereto are true and correct; I <br /> understand that any license issued may be revoked by the District for violation of the LMCD <br /> Code. I agree to reimburse the District for any legal, surveying, engineering, inspection, <br /> maintenance or other expenses incurred by the District in excess of the amount of the <br /> application fee. I consent to permitting officers and agents of the District to enter the premises <br /> at all reasonable times to investigate and to determine whether or not the Code of the District is <br /> being complied with. <br /> I agree to submit a certified, as-built survey upon completion of the docks. <br /> �`�`� --r i U�� �� <br /> Authorized ignature Date <br /> /� '�-�_> `7 �i'✓��N'�'—/Z_ i k � C.;.�4i C' <br /> Title <br /> Return this application,attachments and fee to: <br /> Relationship to Owner <br /> Lake Minnetonka Conservation District <br /> 18338 Minnetonka Blvd. <br /> Deephaven, MN 55391-3232 <br /> Fax: (952) 745-9085 <br /> 2 of 2 <br />