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