HomeMy WebLinkAbout1994 - MCWD app for permit MINNEHAHA CREEK WATERSHED DISTRICT FOR OFFICE USE ONLY
�,�AFIA CA. 14600 Minnetonka Boulevard
..�-F� 11�!F►r^u� e-="r-c hermit Application No. g T -I z/
Minnetonka, MN 55345-13sN\
�=, r"rt i ue Received
Notice Sent
daleop
y'9S_ �' # Agenda Date
NED0\..0 �)j,JI_ 1Z:+
APPLICATION FOR PERMIT- FORM A
SEE REVERSE SIDE FOR INSTRUCTIONS A +SI D
1. OWNER --_ - - 2. OWNER'S
, -1>/, ,L, , j G ,v,e--A/ lt, REPRESENTATIVE:
rap a Type
2--6 D5--- 7,rfjr 4;6 Fri Y -7 %2D ( an c i- o.rnA s c- r--,_ ,
(Address) (City) -- .(Address) --.—
eZ3-3�4 7_, /v/ "(47 ?1 S' Ain-t- \-0.,--- 1f)o - ,
(Telephone) %Z/(r3(� Rip) 3 S 3 3/ .(Telephone) '1 11_ y‘1$ (Zip) c-� 3
es
Owner's Signatu • 7- / '-' GG�!/Cr_..' 0 P.E. 0 RLS. 0 Lk 0 OTHER
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3. Project Location: 1 - 1 1-7 - 2_3 - 2_1 - 0 0 0 `7 --
City 0.A..0-',---0 County .— 1/4 Sec. Sec. Township Rance
4. Project Address: kci 9 Q��°� ) o SS�:_h�kQ.
5. Permit:Requested For: (Check all appropriate boxes)
B. ❑ Stormwater Management Plan C. lY Floodplain Alteration R cu,,.,,,....i,
O • Commercial D. ❑ Wetland Alteration
❑ Industrial E. 0 Dredging
--❑ Institutionai or F'ghway F. Q' Shoreline/Bank Impro•••t'ment
EY- Residential G. ❑ Stream/Lake Crossings
NOTE: Applicants Laying Sandblankets Must Use Application For Permit - Form B -
6. Describe the Project:
P r\wP d- 1un�a.c..` -.c 5 So-E 1 ..�1 ..a.. 1�.••- I. a :y _1 S-A A
. 10 - 2-° D S
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ilfthisjprogect requires municipal approval or review, attach documentation of municipal review.
J- -..- /tel ) -'...- -
' '3odyrf-water, stream or wetland affected by nmoff_from is-sites--Q0.,.\�4_ Y1'1 -�-<<�- _= --
- Distance from project:
8. Schedule for construction, implementation of temporary-erosion control, substantial completion and restoration:
19SA-f
=Please call (612) 939-8320 if assistance in completing this-foe-611S required. In submitting this form,.the app1icaitt`-
acknowledges all requirements for permit approval as determined by the published rules dated May, 1991.
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