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COMBINED JO1NT NOTIF1CATlON FORM-WATCR RESOURCE APPLICATION r�,,,,i <br /> Use this form to notify/apply to the Minnehaha Creek Watershed District (MCWD),their engineering consultants,the <br /> DNR,and the Hennepin Conservation District of a pro�wsed water/wetland project or work which may f'all within their <br /> jurisdiction.These a�encies should advise you of their jurisdiction or pern�it reyuirements within 10 days. Fill out this <br /> form completely and mail a copy,with plan, maps,etc... to the MCWD, 13202 Minnetonka Blvd.,Deephaven, MN 55391 <br /> Keep a copy for your records. <br /> YOU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1.Applicant's Name(Last,1=irst,M.1.) Phone No. <br /> �Ntr-n� A� 65� - �{Z- I8'a� <br /> Address(Sh•eet, RFll,Box#,City,St�te,"Lip) <br /> • o0 0 +. o o N .SS S� <br /> 2. Location of proposed project(Attach drawing w/directions to site): <br /> COUN�1'Y Q"CR SECTION(s) SECTION(s) TOWNSItlP(s) RANGE(s) Lot,Block,Subdivision <br /> ���n���t �f 3 �5 t I 7 �3 eo 5 <br /> Ko��. rA�uk�.ss: 3�{0o FaX �, crrY: o�ono <br /> 3. LENG"CI I OP SI IORE AFFEC'CEU(in feet): VOLUME OF FILL OR EXCAVA710N(Cubic yards): �/O�11 E <br /> Au�A�A.1-�i)QK H�f'F?J IS Acres.OR Syuare F'eet. <br /> �y o � �?�o ac re s <br /> 4. TYP�,OF PERMl1'B�.ING APPLI�,U}�OR: (Check all thnt apply): <br /> �57�0}tMWA�I'ER MANAGEMEN7�PLAN ❑FLO011PLA1N AL�1'ERA�170N ❑WE�I�LAND ALI�ERA7�ION <br /> ❑Sl10REL1NE IMI'ROVEMEN7� ❑S�fORM SEWEk OU'I�E'ALLS ❑ EXCAVA�f(ON(llREllG1NG) <br /> a.�RIPRAP a.❑WILDLIF'� <br /> b.�SANDBLANKE7� ❑ICE RIUGE REMOVAL b.❑NAVIGA�I�ION <br /> c.❑It�."i'AININC WALL c.❑BIO�:NGIN��RING <br /> � n � 1 ❑BRIllG�&CULVERT CROSSINGS <br /> or�i�Kt��scKi��> _ �oSian LA�n e <br /> 4a. APPLICAN7"S KEPKESEN'I'A71VE:(Licensed Contractor,Engineer,etc...) lnclude name,address&phone nwnber. <br /> Scotf I/�,� pe� �n e �Q �60 /l�7 G�l�� w� �l ,SS3 gY <br /> 5. PRO.IEC'i'PURPOSE(why is this project needed-what benefits will it provide'?) <br /> � ,1t�re4s� 'de lu.l��+-a <br /> RCS'�oro�10� o� A�E��1Jc �ct I�'� �o,� wil( GI'e a!o o �„ !o v� <br /> 6.AL'CERNA'fIVES(describe any other sites or methods that could be used to achieve the pumose of your project while avoiding or <br /> minimizing water/weNand imp�cts. Attach additional sheets,if needed. _� <br /> N� <br /> 7. llA7'ES: Propose�i start of activity: M q�--'�ne Ppo� Yroposed completion: �S a�{{'E r S�o(`�' <br /> {��C'1�lf"i.'? a:0i:'^.iet�t�`:r:)I'n Oi:Fiti�:C:":;:�::3CFiLVil1"� �C' (J✓'�t��� <br /> 8. NAMES&AllllRESS 'S OF AUJOINING PROP 'RTY O NERS(Attach list if�uore) <br /> /=?�rn k -�v((���F� ��o z -�ox .�� ��r,_v� .r�ti' SS 35Co <br /> 9. P�RJv1ffS 1lAV�:H�.�.N R�C�31V�U�OR API'Ll�:ll h'OK(Al FROM: llNR ARMY CORPS Oh'ENGK <br /> _�_COUN"fY��C17Y MN POLLU710N CON'1'ROL AGENCY <br /> l hereby notify tlie recipients of this ti�rm of tlie project proposed herein a�id request 1 be acivised of any pennits or otlier detennin�tioiis <br /> conceniing this project diat 1 must obtain. I understand th�t proceeding with work before all required authorizations�re obtained niay be <br /> subject to Federal, State and/or local administrative,civil and/or criminal penalties. <br /> ��✓,� �� D <br /> i�nature of Persor�Pro osin Pro'ect or A ent Date <br />