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JUL-24-2603 13�46 MINNEHAHA CREEK WATERSHED 6124710682 P.03/03
<br /> Permit # �3 - 3`'� �
<br /> Sandblanket Permit and Sand Source Exhibit Form
<br /> FAST TRACK PERMIT
<br /> MINNEHAHA CREEK WATERSHED DISTRICT(MCWD)
<br /> 18202 MiNNETONKA BLVD. Ph: 952-471-0590
<br /> DEEPHAVEN, MN 55391 Fax: 952-471-0682
<br /> .
<br /> I, R� Y � � esid at �o��� " , OaC(j' Q
<br /> �P tt Owner) 6•� � (Add�s) (CiIY�
<br /> /�ri S 5 S�L , ( /2) L�v�k , ranuest approval to instali a sandblanket on property described
<br /> (State�aP) (P el % . ..
<br /> as aG�9��1��w:�•►la:lk'l, •�L�:,.=. . . , �ocated in D�PdA/G.��,�_ , en„e ;v
<br /> �S et address) (V11Uh1 the Clty boundaries) (Count
<br /> on p1i.w�vC�n►+lc�o�. r No� �i�S.�l
<br /> {Propeny 10#(PIO�rp (Laks) � �� (Bay)
<br /> ❑I have contracted with H6 lir,s , �G �oY ,5��
<br /> (Name of Co anYl (Slreet address)
<br /> �-vr� �/ce� . M� . S3'3S� ,_,(.95�.) �/T3-�6C�9 to install clean sand from the
<br /> (ChY� c�Zlp) (Phone)
<br /> following source �
<br /> (Suppllar) (Address) (City,ap)
<br /> �
<br /> (Phone)
<br /> ' ❑ I wili install the sandblanket from the following source ,
<br /> csw�w1e�
<br /> (Add�ess) � (City,State,Zp) � �� (Phone
<br /> )
<br /> / /
<br /> My shoreline is lSS feet and ihe dimensions of the proposed sandblanket are: 50 X
<br /> d' �r X 1�� . Sandblanket dimensions cannat exceed a length of 50'(or 509��o horeline),
<br /> (oop�n) cwidu,)
<br /> a width of 10' and a depth of 6". If this prvject requires municipal approval or review, please attach
<br /> documentation of the municipal approval with this application.
<br /> I understand �at if this application is not c:ompletely filled out, or if I fail to submit the required exhibits, the
<br /> applicatio� is incomplete and will be retumed. It will not be reviewed by MCWD staff until complete. By
<br /> signing this applicatlon, I a9�ee and understand that the District may enter the property at reasonable hours
<br /> to conduct an inspectlon to determine whether the terrns of the permit are being met. I fu►ther understand that
<br /> if I violate the terms and conditions of the permit that is issued based upon this appliration, the DisVict shall
<br /> conduct a field inspection of the project per MCWD Rule J� provided with this application. I understand the
<br /> Dist�ct will charge fees tv cover the actual costs of field inspechons, including investigation of the area
<br /> affected by the work, analysis of the work, including the services of legal cmunsel and enginee�s, and any
<br /> subsequent monitoring of the work.The DistricYs actual costs are deemed to begin accruing when the District
<br /> issues notice vf the violation to permittse. I have read a d n erstand the MCWD Technical Guidellnes for
<br /> sandblankets
<br /> Q �
<br /> ( �gnature of Properry er) -� � (Date)
<br /> ubscribed and s om to b fore me on this�_d of 2p�.
<br /> .
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<br /> �fl���,�,�f� �''�, L�7 LJ�."; r.3 �+:t d:_'. :1 i�i
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<br /> N tary Publi �" ' `�
<br /> ,,; N01qR1►PlI6��'.1�/I�ORA .��� �. �, �'--',
<br /> yrpa�il�6�,1�,�1��111 = ?:��,:
<br /> A roved by: Date — '
<br /> TOTAL P.03
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