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<br /> Permanent Dock Permit Application .T�+-ioR 7lnnro
<br /> ' Page 2 1Qam�e a'rS'f!x'a.
<br /> ...,3,:-• �.'.:.S�S,�'���.I'' .
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<br /> Abutting property oti.�ers at r.he lakeshorcr ���_� '
<br /> � North or Wes[ ��.(„�/ � Qp�y-,��,�y� / 9 �S ��,C�•
<br /> (F.amc and MAILIkC addree�) F'�
<br /> � South or Eaat�j,�,_����c s..rg,�$.6.� :' `� � Jn' ��6�
<br /> i � (Nac� and ?!F'LI2tG addreos,
<br /> Other affected pn-tiea �
<br /> � (NaUc.� and HAILZNC addre�aea - r,ttcch_eheet if necessary
<br /> p4
<br /> T 4. Site Lake fron�agef�_feet{ die[ance of dock iur.o the Lake��fee[.
<br /> S. A1l �etDack� for the 3ock uee area have been ubaerved �)_Ye�LU�7o.—r_-
<br /> � 6. All requlred permlt:s, licenece and approvals heve been ob[ained from G�e Cit�
<br /> in ahich the pexsun+�nt dock is loca[ed, nnd fzom the 2�IDNR� t )Yes O pfl�
<br /> : Explain� ,P�ermit 3pplications '�ave b��n een� _ _
<br /> Y.,
<br /> q � � a v � "�� ..�+t e'�"�s„+ �'� ° k
<br /> .� �.� � /n :CC�Qd �:c:� s '`!� ;'��' �.���s17 .. . •/-,� �p4��Cs.� 7��A�,�"��"*-+`'�;�"�Jia ?�-xY ��-�'� { �:i
<br /> Permit deposit 100 ` - �' . -
<br /> t' Total fee encloeP�' $150
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<br /> ¢ I cartif7 that the information provided herein and the rtCnchmente here[o are eru+
<br /> 3' end correct ete[emente, �nd I underetand that any percic gran[ed may be revoked b�
<br /> the Metrict for violation of the LHCD Code. I agree to reimburee the Diatriet for ;;,. .
<br /> �4� any legal, surveying, �n3ineering, in�pection, maintennnce or other expen�e iacurred f lf J �� �,,'
<br /> � by tt�e DLetrict in ezce•e of the amount of depoeit. I consent to varmitting of- y# �
<br /> fieerc and agent� of tte Dletzict to enter tha preaiees involqed.at all r�aeoaabla i '�=; �
<br /> - -• <'tiwekio�:inv�etigate':an�t%to�,dete�aine'-vhethar�tha'�.Coda"'Ofisb�'D1�LTi0C� '�"��: . ''� .'
<br /> conpiied xith. . . . . : �� y���� ry'
<br /> - Auihorized eignnturc �
<br /> � �
<br /> Dn[� Titl �- 'G.:l�Lt �
<br /> i
<br /> � Rtturn application and attachmenta to: Lake Hinne[onka Coneervation Dis[rlct
<br /> 402 Eeet LaY.e S[reet
<br /> Wayza!a, HN 55391
<br /> :
<br /> Phone: �612) 473-7033
<br /> 12/84
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