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Sandbianket Permit and Sand Source Exhibit Form ;��, ,-, - „-
FAST TRACK PERMIT ��j�� �%� i� ;� �� ,�
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MINNEHAHA CREEK WATERSHED DISTRICT(MCWD) ��°�f ��Pf 2 7 �pT� ;,C,'�
18202 MINNETONKA BLVD. Ph: 952-471-0590 �� �
DEEPHAVEN, MN 55391 Fax: 952-471-0682 �y___`
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I,-���c1������ ��r.���� � reside at ��<5�� 5 ,1��>io, � �� �Z�=i G�
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(Property Owner) ��) �C��,)
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��lt�` ������,`� / , ,•l,t �if1 • .� ��.s � request approva{to install a sandblanket on property described
(State,Zip) � (Phone) ,
as q v l S�(�rlcr �'!l 20� , located in �/L�Y10 , i
(Streetaddress) (Wnhin the City boundaries) (County
�,G I!;f-13�y�l�0�'D.�- on � G�� - _,
(Property ID#[PID#J) ake} (Bay}
�I have contracted with >�i j^� S ��,, u�r� �� �t��/ )�"�r.4 r'-L��� �V /�c+ ;�-- ,�"�J,�
�o,e (Name of Company) (Streat address)
���� ?�%� � J��� � �`� ���� , �(� �<: � �`�:1. 7� to install clean sand from the
(City,State,Zi (Phone) �
following source j)IV� I^�C�l:i Ili� l°lcJ � ��'�T'l� �Y��v`�u�'� / 61%C !f'i�i l°) 1���(,f•���,�f(,J
./7 L��.S.i�.
(Supplier) � ' (Address) (CitY, iP)
(��) ��/�i �!,`�I.� J(J
(Phone)
�j I will install the sandblanket from the following source � �'--t� �/: V�� j� k r,.i�, '�.,,�
(Supplier)
`�'?7� �",�',r„�,-z li„e S v`�f., Lv:,cv��1„i i►r►iV _S.S��l� , ;,� � `�/�l-�i 7/�
(Addross) -� (City,Stata,Zfp) (Phone)
My shoreline is`1wT feet and the dimensions of the proposed sandblanket are: S�� � X
�,�i (Length)
X �4 . Sandblanket dimensions cannot exceed a length of 50' (or 50% of shoreline),
( ept I t
a width of 10' and a depth of 6". If this project requires municipal approval or review, please attach �
documentation of the municipal approval with this application.
I understand that if this application is not completely filled out, or if I fail to submit the required exhibits, the
application is incomplete and will be returned. It will not be reviewed by MCWD staff until complete. By
signing this application, I agree and understand that the District may enter the property at reasonable hours
to conduct an inspection to determine whether the terms'of the permit are being met. I further understand that
if I violate the te�ms and conditions of the permit that is issued based upon this application, the District shall
conduct a field inspection of the project per MCWD Rule J, provided with this application. I understand the
District will charge fees to cover the actual costs of field inspections, including investigation of the area
affected by the worK, analysis of the work, including the services of legal counsel and engineers, and any
subsequent monitoring of the work. The DistricYs actual costs are deemed to begin accruing when the District
issues notice of the violati to p mittee. 1 have read and understand the MCWD Technical Guidelines for
san a ket .
��a� � z-d/O
ignature of Pro rty Owner) (Date)
Subs ibed and sw rn to before me on this� ( fr)'1u¢��p,�
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Notary Public I
7���' Minnesota
Notary lic '""' My Commission Explres Jan.31,2014
Approved by: Date 7i ��