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JIfL-14�200.3 15�12 MINNEHAHA CREEK WATERSH�D 6124710682 P.05i06
<br /> . � .
<br /> SANnB�.A'�`r`�!��t1VIIT,& S�ND SOt1RCE EX�-IIBTT FORM� .
<br /> � CREEK VITATF.�.SHED DIS1'RICT . '
<br /> � ' � � �ruuttT�_����
<br /> l, residina at c��11,�',� �.� A �/!'l„��
<br /> Proherry Owrier Addnrss City,9�te.7.ih
<br /> �Q �' f�'��� ,,�N!'� or P1D#11 Q-1�1�-.,2/-ed/
<br /> ��_ �.:
<br /> Phone GOunly Township,Saclfon,�:18� �R+P�P�R'7 ux sialo�t�cR1t)
<br /> own and occupy thc above sir�gle�am�ily�eaidenoe �n,d wish to instal�a sax�dblar�kret on
<br /> /�1�- rI'I�x�o����.
<br /> ��s�,
<br /> Minnetcnka Portable Dredging
<br /> � I l+ave oontractrd wit� at
<br /> `°�sior� MN 55331 to install cltan sand fcom the following sou
<br /> eltY�s�te.aip phone
<br /> /h,�•c.c�e b►��./ �i�ti�i3ue� 112iv. , S��`' �11 ?S ,or.
<br /> ���s��� '— s�deess p�+o�+e
<br /> ❑ I will ie�sta�l the sandbl�nlxt mysclf from the fellowir�g�oura.
<br /> . �pptier
<br /> addresc - ---- -- phone
<br /> Yf this pz�ojecE requixes �nunieipal approval or review,plc�se a�tach docutnenEaliop of the municipal appc
<br /> . with this application. My sho�eliY►e is � feet a�nd the dimensiot�s af the propos+:d sandbla.nket are:
<br /> ,�(Y.ength) x �.,,_ �idtk�) x� (Depth).Sandblank�t dimension.c can�et exceed. a
<br /> letlgth of SO' (or 5096 of shor�line),a width of 10'and a dcpth of 6".
<br /> 1 understarid that if thi.s application is not cotnplcteLy filled out, or if i f�il to submit the renuired exhi
<br /> tlte applicatioti is incomp]�ete end will be ketu�acd. It will not bc reviewed�by MCWD staff until eomE
<br /> By signir�g this appliration., I agree and ur.d,eex�tand that the District may ent,er the pcoperty at reasor
<br /> hours to corduct an uupection to defermine whetker the terms af the permit at+e beirtg met. t fut
<br /> unders4atud'tha! if I �iolaee the k�cm„e and conditions oE a p�rmit.that ix issued b�sed upan this applica
<br /> tha Distriet�hall e.onduct a fiedd inspcction of tlie projeet per MCWD R,ule J, provided with this app].ica
<br /> t understand tke Distt'►et will el�axge#ees to cover the actual costs o�field ir�specliox�s, in�luding invutig�
<br /> oF the araa affected by the worlr,s�ysis of the work, ix�cltiding thc services of le$al oounsel and eng��n
<br /> and any subsequent monitorir�g of!he work, The Distr�i,ct's actual cas�s are deetned to begin accruing +�
<br /> tht Dist�i.ct issucs notia of the vio(ation to the permittee, I havo r�ad and understand thc Mc:WD Tfch�
<br /> Cuidelines fo sandblanke .
<br /> � � �l� � �
<br /> S zr Date
<br /> _.�,.
<br /> Suhscribed and sworn to befo�e me this day oE � 200� �
<br /> � �� �-�' ��.��..C,� ��, ,
<br /> r �
<br /> � /a TM_ SUSAN NOfiN A : i�.� � �►
<br /> � � `.� �����, �:,� �uN ��. ��
<br /> Nata. Pub[ic . .,.,,.t�;:��, ` . ;S
<br /> ry . , �3� ,� A�
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<br /> �
<br /> �.�.��v � ..,�.�.e:..e..�.a.
<br /> Approvcd and�►cccpted by Oa e
<br /> ��.....rt_C.._� �:_�..T...1.-.l.. ..
<br /> se•d 6e:9ti �0ez-vi-�nr
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