Laserfiche WebLink
I <br /> MAR—f4-2003 12:46 MINNEHAHA CREIB< WATERSHED 6124710682 P.07/12 <br /> COMBINED JOINT NOTIFICATION FORM-WATER RESOURCE APPLICATION apps <br /> Use this form to notify/apply to the Minnehaha Creek Watershed District (MCWD),their engineering consultants,the <br /> D'4&and the Hennepin Conservation District of a proposed water/wetland project or work which may fall within their <br /> jursdiction.These agencies should advise you of their jurisdiction or permit requirements within 10 days.Fill out this <br /> fo'm completely and mail a copy,with plan,cups,etc..,to the MCWD, 18202 Minnotonka Blvd.,Deephaven,MN 55391 <br /> 7 ep a copy for your records. <br /> YOU MUST OBTAIN ALL RE UIMfiD AUTHORIZATIONS BEFORE BEGINNING WORK, <br /> 1. pplicant ri Name(Las4 First,M.1.) Phone No. <br /> ori Q9- 96 a.- 7-49 - 11 soot <br /> ddress(Straet.RFD,Box#,City,State,Zip) <br /> $45 =.cot r, mkwrm Q rvlziT SS 31 <br /> 3.1 Location of proposed project(Attach drawing w/directions to site): <br /> C�GUNTY QTR SECTION(s) teSECT(ON(s) TO SHIP(s) RANGE(s) Lot,Block,Subdivision <br /> � GSp4 ri 49 C I�loar�Sw�n.r: a.�E <br /> PROJECT ADDRESS: 210 r►.aD Z"10 NSnwe.e e.CITY: Oto rl O <br /> 3. LENGTH OF SHORE AFFECTED(in tbet): VOLUME OF FILL OREXCAVATION(Cubic yards): <br /> AREA FILLED OR EXCAVATED IS Acres.OR Square Feet. <br /> 4. TYPE OF PERMIT BEING APPLIED FOR: (Check all that apply): <br /> ST,ORMWATL•R MANAGEMENT PLAN 0 FLOODPLAIN ALTERATION ❑WETLAND ALTERATION <br /> SHORELINE IMPROVEMENT []STORM SEWER OUTFALLS ❑ EXCAVATION(DREDGINO) <br /> ❑RIPRAP a. WQ.DLIFB <br /> E <br /> S,NNDBLANKCT ❑CCE RIDGE REMOVAL b.s NAVIGATION <br /> RSTAM 0 WALL c.I]DIOENGWELRINO <br /> ❑BR=E&CULVERT CROSSINOS <br /> 0 HER(oCSCRtBE) �e.�SF`e Zt.� P1,�r�, ..� •r n 2.- 1.7 Law <br /> ,.1 Ca T �- �► 4� 'P 7 7.0,.1 T <br /> 4n APPLICANT'S REPRESENTATM;(Licensed Conuactor,Engineer,ctc.,,) Include name,address&phone number. <br /> 5. ROJCCT PURPOSE(why is this project needed-what benefits will it provide?) eonP �E <br /> r� q 1a <br /> o T�nu.oE A b% -,aLuiny 76tem 5 Tvig''��.a•Q �rrt.S T • l euposca---Tor tS 4L03 tb+a Mal 4% <br /> 6. 1LTERNATIVES(describe any other sites or methods trice could be used to achieve the purpose ofyour project while avoiding or <br /> nimizing wateNwadand impacts. Attach additional sheers,if treaded. <br /> 7. ATES: Proposed scare of activity; a¢�� Z,oc.,3 Proposed completion: M qy 2 a o3 <br /> (Identify apy completed work on attached drawing) <br /> 8. NAMES&ADDRESSES OF ADIOINING PROPERTY OWNERS(Attach list if more) <br /> 9. PED41TS HAVE BL93N RECEIVED (it)OR APPLIED FOR(A)FROM:SNR ARMY CORPS OF ENGR <br /> COUNTY—X-CITY MN POLLUTION CONTROL AGENCY <br /> 1 ercby notify the recipients of this form of the project proposed herein and request I be advised ofany permits or other determinations <br /> co ftcaming this project that I must obtain.I undet'stand that proceeding with work before all required authorizations are obtained may be <br /> su jeer co rat.State and/or local administrative,civil and/or criminal penalties. <br /> -1' .0 <br /> Si►na[ura o Person Pro sin Pro eet or Agent Date <br /> 701'.4 ;PTC`RCJ <br />