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NA- 02670 -01 <br />(W -221) <br />(Rev 74) <br />STATE OF MINNESOTA <br />DEPARTMENT of NATURAL RESOURCES <br />NOTIFICATION OF PERMIT APPLICATION <br />INSTRUCTIONS FOR THE APPLICANT <br />Minnesota Statutes, Section 105.44, Subdivision 1, requires you to supply a complete copy <br />and all supporting data of your water permit application to the following: <br />V The chief executive officer of the city or township within which <br />the project is located. <br />B) The secretary of the Board of Managers of the watershed district, <br />if any, within which your project is located or which your project <br />may affect. <br />You MUST certify having served the complete application on the above in the box on the back <br />side of the application form W -S4. <br />IN ADDITION, if your project is NOT located in a city, a complete copy and all supporting <br />data of the application should be submitted to the Administrator of the Shoreland Manage- <br />ment Program for the affected county. <br />Complete this form for each notice served on a local government official. <br />* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * <br />SECTION I (TO BE COMPLETED BY APPLICANT) <br />TO: A) Chief executive officer of the (check) <br />city, n township of LITTI[ t?NPh i <br />(print or type name) <br />B) Secretary of the board of managers of the watershed district. <br />(print or type nave) <br />C) Administrator of the shoreland management program of county. <br />(print or type name) <br />f.f;Ke't &gam' r4sut \ hry-s Defy <br />FROM: I31R N'- FAc£ S i . S� 4Ruk ANA, 5 510._ <br />(print or type name and addreae of applicant) <br />Date: ,)llac 11 19 gi <br />* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * <br />INSTRUCTIONS FOR THE LOCAL GOVERNMENT <br />This report from provides you an opportunity to submit input to the Department of Natural <br />Resources to assist in deciding whether to grant, modify, or deny the requested permit. <br />It is NOT absolutely necessary for local agencies to officially approve or disapprove the <br />project or make any recommendation, although this may be done if desired. It is requested <br />that local agencies indicate the following, as applicable: <br />A. The relationship of the proposed project to local plans for the <br />affected water and related land. <br />B. The relationship of the project to local land use controls including <br />flood plain and /or shoreland regulations. <br />3q <br />(continued on reverse side) <br />