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COMBINED JOINT NOTI�'ICATION FORM-WATER RESOURCE APPLICATION ,�p <br /> Use this form W notify/apply to d�e Minnehaha Creek Watersh�d District (MCWD),their engineering oonsultants,the <br /> DNR,and the Heimepitt Co�nseivatio�District of a proposed water/wetland projoct ac wark which may fall within t�ir <br /> jurisdiction.These agencies should advise you of their jurisdiction or pennit requirements within 10 days.Fill out this <br /> form complexely and mail a copy.with plan,maps,etc...tu the MCWD, 182021��innetonka Blvd.,Deephaven,MN 55391 <br /> Ke�p a copy for your ra�ds. <br /> YOU MUST OBTAIl�I ALL REQUIRFD ALTI'HORIZATIONS BFFORE BFGIIVNIIVG WORK. <br /> 1. 's Name First,M.L) Phoae No. <br /> Addc+ese( traet,RFD,Box#.Cit3',Stau,Zip) <br /> • ,,� <br /> 2. Locati�of proposed projxt(Auach drawing w/di�ectioos to sitt): <br /> CQUNTY QTR SECTION(s) SFCPION(s) TOWNSH�'(s) RANGE(a) Lot.Block,Subdivisiaa <br /> /�s��sp.t a _ <br /> PRO]ECTADDRFSS: $ ''✓J �E ' CTfY: � <br /> 3. IENGT'H OF SHORE AFFF.GTFD(in fcet): VOLUME OF F1LL OR FXCAVATION(Cubic yands): <br /> ARFA FILi�D OR EXCAVATFD IS A�res,OR Square Fcet. <br /> 4. TYPE OF PERMIT BEINCi APPL.II�.D FOR: ((�ock all that app1Y). <br /> ❑SPORMWATFR MANAGE[v�lVT PiAN ❑FI..O�DPLAIN ALTFRATTON ❑WETiAND ALTFRATION <br /> �5HORFLIIVE IlNPitOVE[uII�TP �S"I'ORM S�VVFR OVIFAILS ❑ EXCAVATION(DREDGING) <br /> a WIIDL�E <br /> b SANDBLANKET ❑I(B RIDC�REMOVAL b�NAVIGATiON <br /> c.�1tEPAININ(3 WAii, c.�BIO�NC�IN(3 <br /> �BRIDGE&CCTLVERT Cxt05SINGS <br /> OTI�R(DESCRIBE) 5�.�1�l=a..:�„ t�eM� <br /> 4a. APP�.ICANT'S RFPRESENTAINE:(iiceaeed Cant�ractor,Engi�er,etc...) Inch�de name,addc�ess 8c phooe munbec. <br /> �� <br /> 5.PROJF�GT PURPOSE(why is thia projax needed-what beaefits will it provide� <br /> ----. <br /> 6.AL.TFRNATTVES(�'be any other sitea or methods that oould be ueod to ac�eve the puipoee of ya�r project while avoiding or <br /> ai�iniang wa�edwalaod imp�c�s. Attach additional sheets,if needed. <br /> -� <br /> 7.DATFS: Pivposed start of a�ctivity: Sep�. l S 03 Proposed coa�pldion: �"�b. IS Oy <br /> vwak an attached dra ' <br /> 8. NA1NE.�,/ �pDRESSES OF ADJOINII�IG PttOPIItTY OWNERS(Auach list if more) <br /> y� �� <br /> 9. PERMITs HAVE Bffi�t RF�CIIVFD (R)OR APPI�D POR(A)PROM: 'DNR ARMY OORPS OF E[�1C3R <br /> QOUNI'Y_�CTI'Y MN PCULUI'ION QONTROL ACiII�1CY <br /> I harby n�dfy tlie rxipie�ts of t6is fam of the projeat pmposod h�in aod request I be advised of any pamits or otha determi�ations <br /> oonoaning this pro.ject mat I muet oMnin.I�mae�nd thac p�ing wim wadc t�efooe an requiroa au�ocizations are obtainea may be <br /> aubjax State local sd�ninistcative,civil and/or criminal penaltiea. <br /> s; � � �„�• a <br /> 9 s o <br />