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Wall Office of the Sheriff 0�� b.. <br />County <br />F�k�'� <br />Commitment to Exceffence <br />William M. Hutton <br />Sheriff <br />Dan Starry <br />Chief Deputy <br />APPLICATION FOR WATER SURFACE STRUCTURE USE PERMIT <br />To Place a raft, buoy, or other structure on or in the waters of this county pursuant to MN Rules 6110.1800 <br />Name: , f 1 ' P A L vZ— Cell# �f" �(' � ' �i fs <br />Address: r� �( �—' (ZZ Work#: Fax#: <br />/, 20 114 lY Zip Code: 1 �� 7 <br />P �� <br />Type of structure: /I Body of water: u/Yet' L t r Dates:_ — �� <br />Permit requirements: Applicant shall maintain a comprehensive liability insurance policy in the amount not less than <br />three hundred thousand dollars ($300,000). The policy shall remain in effect for the duration of the effective dates. A <br />Certificate of Insurance must be supplied to the Sheriff's Office with the permit application. <br />I the undersigned applicant, agree to hold harmless Washington County for any and all claims resulting from the structure <br />specified on this application. <br />1. Diagram of water surface showing placement of structure, include the depth of the water at the <br />location of the structure. <br />2. Permit must be issued before structure is placed on or in the water. <br />3. Floating rafts, swim buoys and mooring buoys must be placed between the permit holder's property <br />lines as they extend into the water. These structures must be within 100 feet of shore. <br />4. Structure must display proper reflective material as described in MN State Rule 6110.1800. <br />5. Permit number must be displayed on the structure using numbers that are at least two inches high <br />and a contrasting color to the area where they are attached. <br />6. Water ski slalom courses and water ski jumps must be approved annually by the City Council or <br />Township Board where the course will be located, special restrictions may apply. Slalom courses <br />cannot exceed 900 feet in length and must display the permit number on the end floats. Slalom <br />courses and ski jumps cannot be a navigational hazard. Water ski jumps must be lighted during the <br />hours of darkness. <br />City/Township Representative printed name: <br />Signature: <br />Signature of Applicant: <br />Date: <br />Law Enforcement Center • 15015 62nd Street North — P.O. Box 3801, Stillwater, Minnesota 55082-3801 <br />Phone: 651-430-7600 • Fax: 651-430-7603 • TTY: 651-430-6246 <br />www.co.washington.mn.0s <br />Equal Employment Opportunity / Affirmative Action <br />