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<br /> PERMAN�NT NON-MULT.IPL�DOCK LIC�NSE APPLICATTON
<br /> Lake Minnetonlca Conservation District
<br /> � � ���'� � 18338 Minnetonka Blvd.
<br /> i - '�a�,.��,
<br /> �' �� MN 55391
<br /> �,���:.;_��'�,�»��-� a Deepl7aven,
<br /> :�,�:�,�
<br /> ' �`�"`" � Phone (952) 745-0789
<br /> . �.
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<br /> . LMCD Receipt#��� . _ .._. . , -, _ _. _
<br /> In accordance with Sec.2.06 of the LMCD Code,the following application for a permanent Dock License shall be
<br /> completed in al1 respects and submitted to the District office. No person may locate,construct,install or maintain a
<br /> new permanent dock on the lake witliout first securing a license providing that no such license shall be required of
<br /> docks requiring a license under sec 2.03 of the LMCD Code.A new license is required whenever the size,type,
<br /> location,or configuration of ihe dock is clianged. No new ticense is required for repair or repIacement of a previously
<br /> pern�itted dock where such repair or replacement does not alter tlie size,type,location,or configuration of tlie dock.
<br /> Because this fornz is to be copied,please use black ink or type.
<br /> The person completing this fonn is the authorized agent or property owner(circle one).
<br /> Applicant:_ t,�/'I h1�Pfnh lia /�/�d��Z�P f���'i%1 q
<br /> Address:_ h UD �A1 P,sf �i�/�a S77'�Pn�' - - - -
<br /> City, State,ZiP'_ ��'«����,' �/l� ��.���
<br /> Phone:_ cjsZ-�7�/-c/�,1�'(� Fax: 95Z-�7�-(07/Z
<br /> Property Owner(if different from applicant): f�o /� �v�c�C i /�
<br /> Address_ �72, If��sf (��.•2 S..f.
<br /> City, State,Zip: ,Q/�ji1/�� � tif� .��3.�CP .
<br /> Phone: �/S�� `��s'— ���"'� Fax: �'�Z 7.�— 7a-Z�--
<br /> Documents Iisted below are required; and must accompany this application:
<br /> ❑Locator Map ❑Scaled drawing of docks on abutting properties ,�Q{�I.�
<br /> ❑County Plat Map ❑Proposed facility site plan
<br /> ❑Certified Land Survey, Legal Description ❑Existing facility site plan
<br /> Absence of significant requested data, could result in a processi�zg delay.
<br /> 1. Type of facility �(private ()multiple dwelling
<br /> () commercia! () other(expIain)
<br /> 2. Intended use of dock facility _ �Shi�o alac�/ rP ��Q�{i�M G'h� /rJQSV�'1�l
<br /> .-.., .�....___._......._. __.., .... -.,,�..,�.,.._,...--. ._. . . ._...�,. .. _ �-.�
<br />._._.__. _ .� . s...-- _ _ ..-. W�c�2r Y_.__�.__.. ..�. K
<br /> 3. Abutting property owners at tlie lakeshore:
<br /> North or West M/��MPS �bw�N �, �-r��-� �/�� -��NK��/� �2D� OrC'O/1J0���1 s`�`'�,G
<br /> neme and address
<br /> South or East N�P �K,� N{ �c��E� /� s H���b5 357.� �MR rsTw� A,�, o�eo.,Ja �M�1 Ss'3sq
<br /> name and address
<br /> Other affected parties
<br /> name and address �• :.
<br /> �i'I, � .
<br /> 1 ot'a I�'
<br /> ����..� JAN i 9 2006 ;. .
<br /> ijjl �
<br /> GYr---. . .__. �---- ._I
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