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� <br /> " 'WATER R,E$OtJ[tCE pSBM1T APp'L�TCATION�COIV�INED JOYNT NOTIFICATION FORM <br /> � use ie;c ror.a co nonh�/�vtr a the r�s�nn.haba Qeek waoers�ea 1�aice ct�tcwD).t�,ci:cnp�enns consulwac�,and che l�r►tt or u <br /> ProP�PoJ�ot v�art whicL nu�y tail�ritsin thair jurisdictios.Thep agRlci�i=houid adviss you vf that ju�sdic6on or permlt <br /> req�within 10 day�PiII ouc tt�is form oo�lately snd m�nl w:tb yoat sioc plen,n��dc...ev Me MCWD.t6202 Mitu�ttnnka <br /> boufewM,Dc�haven,MN S5391_Keep a arpy boc your rotords. <br /> YOU MUST OBTAIl+�AI,L REQUIItFD AUTHOR1ZATfONS BEFORE BECiINNI1�TG WORK. <br /> I.Prvpeity Owner Name(First.Last�: � � = �s • <br /> Msiling AddcE,�s:�,�, Ps�two�dew� wp.y City: L,� ��k� Sta�e: �' ,N _ Zip:�535ra <br /> Em�il Address: Phone: (etZ 850 �Z7 Fax: <br /> 2•Location of proposed ptoject tA�map with dizeecions to site): <br /> Ptoject Addtitss: 3125 �,Oar st City: �alk•� <br /> County: �,���Qtr Seccion(s): S�rio�{s): Township(s): " Rouige(s): <br /> Lot: � Block: Subdivision: uv6s'C PID: <br /> 3.Siu of sica; 3ly.st x ��_:�l Aces of excavation(ot fill): 3o5Cn sq[t�or acres <br /> Vvlume of exoavation or ftll : �vbic fcet L�n of shonline affected: feet <br /> 4.'I)+pa of pera�it being applied for(Ctteck all that ap�� <br /> Q'�ItOSION CONTl20L AND A1.7ERAT[ON <br /> CJ ST'ORMWATER MANAGLM6N'�' 0 WATniBODY CROSSII�lC <br /> CI�,OODPI,AIN ALZERATION C7 SAORBL,iNB/S'TRBAMBANK Q�'ROVEIN�'.NTS <br /> M�BDC�iC ' <br /> 0 OTl�R E� � <br /> 5.Project P�upoae(Check ell ttwt app3y): <br /> �'SII�IGI.B FAMII.Y HOMfi 0 MULTI PAMII.Y RE5IDEIV`fIAL HOUSlN(3(apattments.etc.) <br /> 0(:OND►dFRCxAI.CONSTRUGTION a INs�rrvrioiv�,coNs�vcriox c�►�t,�.$��:,�,� <br /> ❑ROAD CQNS?ILUCi'10N " 0 SUBDN�IONS(inc{ude numbri of iws) _ <br /> D� O 1.ANDSCAPIN�(pools.br�,etc.) <br /> a n�eoc�n�r� a sHot�r.nvE srAsa.�zwTzorr a��,�«��,�) <br /> 0 or� ��: <br /> 6.Alternad ves�escribe any other sites or method=that coold 6e•uaed to avoid o�'minimiu impaC�s to water <br /> bodies to schieve the project pueposed.Aaach addidunal aheet if needed.) <br /> 7.Pro� 7'imeline Statt Date: A/ y �.1 C ledoa Dste: OV 6 <br /> 8.Applicants Itcp:eaa�cadvn(LicBnaad coaaaccor,dnginaer.etc...) <br /> Hus�ness Nsme: l.-�+�.� N +�sa�+ �e•rst. �.� iicp�+eseatstivc Name: -��� N�LSa�.� PR�se+c <br /> Husuness Address:�1.5 �..sT A� N Ctity;�'sa�vl'r Stata:�,_Zin: s6�lv <br /> Finait Addrr,ss: Pi�one• 2 Fax: <br /> 9.Names und adcl�esses of adjoining�opacty owncrs(Auach li�t if necessary) <br /> 5�E L�rt�� . <br /> .—._._,.�,_..... .. <br /> Permits have ban applied:Clty County MN Pollutian Cvmivl Agency DNE��CO�„_ <br /> P'ermits have b�,en receival: Cit Coun NIIV Pollation Coa�+ol D COE <br /> 1 h�eby twt;rr�rzcipic�oF n,;s rorm of ehe poiect propwed h«eiR sad reque�c[be sdvised ot any pamto.or od�er <br /> de�erWim�tions eoncetniqg t6is po,ject that 1 must obttin.I undm�d that proeeeding witb w�ork bet+ore all requited autlw�iLa6ons <br /> �ro ined may be subjeet�o r'�eral.Staoe aad/aor locat admieiistntivt.tivlt aod/ar cri�nind panslties. <br /> �- ` �? <br /> � <br /> Si re f Owner DaOe � <br /> _ _ . _ _ �a���, --� <br /> �,:° �:.�-� � �' ��- ��il <br /> Page 1 of 2 � �a 1 � � �1 <br /> �� �:�:; o � 2e�4 <br />