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�c� Office of the Sheriff Commitment to Frcefience Dan Starry Sheriff Brian R. Mueller Chief Deputy APPLICATION FOR WATER SURFACE USE PERMIT To Place a raft, buoy, or other structure on or in the waters of this county pursuant to MN Rules 6110.1800 Name: David Strub Home#: 6514293053 Cell# 6514028654 Address: 12670 Incersoll Ave N Work#: Hugo, MN _ Zip Code: 55038 E-Mail: daveCa!strubnetnet Fax#: Type of structure: slalom course Body of water: Sunset Lake Dates: Mav 22 2018 - Oct 31.2018 Permit requirements: Applicant shall maintain a comprehensive liability insurance policy in the amount not less than three hundred thousand dollars ($300,000). The policy shall remain in effect for the duration of the effective dates. A Certificate of Insurance must be supplied to the Sheriffs Office with the permit application. I the undersigned applicant, agree to hold harmless Washington County for any and all claims resulting from the structure specified on this application. 1. Diagram of water surface showing placement of structure, include the depth of the water at the location of the structure. 2. Permit must be issued before structure is placed on or in the water. 3. Floating rafts, swim buoys and mooring buoys must be placed between the permit holder's property lines as they extend into the water. These structures must be within 100 feet of shore. 4. Structure must display proper reflective material as described in MN State Rule 6110.1800. 5. Permit number must be displayed on the structure using numbers that are at least two inches high and a contrasting color to the area where they are attached. 6. Water ski slalom courses and water ski jumps must be approved annually by the City Council or Township Board where the course will be located, special restrictions may apply. Slalom courses cannot exceed 900 feet in length and must display the permit number on the end floats. Slalom courses and ski jumps cannot be a navigational hazard. Water ski jumps must be lighted during the hours of darkness. City/Township Representative printed name: City/Township Representative Signature: Signature of Applicant: Date: Law Enforcement Center • 15015 62nd Street North — P.O. Box 3801, Stillwater, Minnesota 55082-3801 Phone: 651-+430-7600 • Fax: 651-430-7603 • TTY: 651-430-6246 www.co.washington.mn.us Equal Employment Opportunity / Affirmative Action