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JUL-08-2003 14:38 MINNEHRHR CREEK WATERSHED 6124710682 P.03i08 COMBINED JOINT NOTIFICATION FORM-WATER RESOURCE APPLICATION apps Usc this form to notify/apply to the Minnehaha Crock Watershed District (MCWD),their engineering consultants,the DNR, and the Hennepin Conservation District of a proposed water/wetland project or work which may fall within their jurisdiction.Tltcso agencies should advise you of their jurisdiction or permit requirements within 10 days. Fill out this form completely and ittail a copy,with plan,maps,etc.., to the MCWD, 18202 Minnetonka Blvd., Deephaven,MN 5S391 Kccp it copy for your records. YOU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEG1NNiNG WORK, 1.Applicant's Name(Last,First,M.I.) Phone No, L-oatye,;-a SMS. rCJSTRvt,T.a, 1 93 Z. Z49 - `f Soot Addruss(Street, RFD,Box#, City,State,Zip) ,5ti5 Z a o t iDy w� Q 17 a za IQ 'e- 2. 2. Location of proposed project(Attach drawing w/directions to site): COUNTY QSS,3LCTfON(s) SECTION(s) TOWNSHIP(s) RANGI:(s) Lot,Block,Subdivision CSAr♦ 1-! S NaM1 ��,vim,PROJECT A RE21 o 0 2�o NSf4�� 1��. CITY: 0Ro PJ t7 3. I.CNGTH OF SHO 'CTED(in flet); VOLUME OF FILL OR EXCAVATION(Cubic yards): AREA FILL R EXCAVATED IS Acres.OR Square Feet, 4. TYPE OF PERMIT BEING APPLIED FOR: (Check all that apply): ❑STORMWATZR MANAGEMENT PLAN ❑FLOODPLAIN ALTERATION ❑WETLAND ALTERATION (SHORELINE IMPROVEMENT ❑STORM SEWER OUTFALLS ❑ ExCAVATION(DREDGING) a.❑RrPRAP a. WILDLIFE b.❑SANDBLANKET ❑ICE RIDGEREMOVAI_ b.0 NAVIGATION c.❑RCTAINING WALL c,❑810ENGME•RING ❑BRIDGE&CULu1=RT CROSSINGS OTHER(DESCRIBE)-_IiL naSFF-e. : Zt.n To L.�0apa.a�a 'C3F�t?S cstnLT��T'°^• uuL — t:_R.eSio•� Coa-rP-oma. Arr 'R�-ES l7 WE'r��sG pcLnTq-c.,7,Q..1 �12_r.tiT._ ,_._.__..._ 41. APPLICANT'S REPRESENTATIVE:(Licensed Conrractor,Engineer,ctc...) Include name,address&phone number, S.PROJECT PURPOSE(why is this projcot needed—what benefits will it provide?) eonP11E .a To 1�Qou•o�. n �2.�EwnY To RISS T�t6 '�,-att o ��rt.S TN• 4103 k?'a Ihnyeg 6.ALTLRNATIV6S(describe any other sites or methods that could be used to achieve the purpose oryour project while avoiding or minimizing water/wetland impacts. Attach additional sheets,ifnceded. 7_DATES: Proposed start of activity: P Q„ 2 o v 3 Proposed completion_ M e`l 2 v o3 (Idcnti any completed work-on attached drawing) B. NAMES &ADDRESSES OF ADIOrNING PROPERTY OWNERS(Attach list if more) 9. PERMITS HAVE REE-N RECEIVED (R)OR APPLIED FOR(A)FROM:___DNR ARMY CORPS OF ENGR COUNTY__X_CITY MN POLLUTION CONTROL AGENCY I hereby notify the recipients of this form of the project proposed herein and request I be advised of any permits or other determinations concerning this project that I must obtain.I understand that proceeding with work before all required autherizarions are obtained may be subject;Dzal, localadministrative,civil and/or criminal penalties. -t '? .o3 Signature o Pcrson Proposing Project or A ent Date 7('i1'J 7TC,MQJ497CC K,ni CMM 'O C=nWC -%an e-4,-rAT C"MIM7-e T_�1LJL1