5.d) Slalom Course AppWashington Office of the Sheriff ��
County VI C '
Commitment to ETceffence
William M. Hutton
Sheriff
Dan Starry
Chief Deputy
APPLICATION FOR WATER MIX, ACE STRUCTURE USE PERMIT
To Place a raft, buoy, or other structure on or in the waters of this county pursuant to MN Rules 0110.1800
Name: t e' n c�,c, L ,
-TV-";,
2 ✓ HnmeH: BSI -433 -4�d� ear,_ �5l - /ZZ�E -SZ aS
Address: Z3290 Nei c..,.; e V-";, Workff4Sl-/-4C1-SZWF:u#: N/A
a
s cc.-1. _ .V\M Zip Codc: �SG7 3
E-Mail: T c o-�.er 0 ot:m r.: e C j v"1
Type of structure:s Bodyofwater: Q-he Luke tlates:5 t7 l�F -6 ko isXA
Permit requirements: Applicant shall maintain a comprehensive liability insurance policy in the amount not less than
three hundred thousand dollars (S300,000). The policy shill remain in effect for the duration of the effective dates. A
Certificate of Insurance must be supplied to the Sheriff's 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 file 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 PIN Slate 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 :rod 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 feel 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. lc) ( Z_
Signature: `Wi
%"11�
Signature of Applicant:
S -2Z- 1zk_
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 I Affirmative Action
aS+na7 ,rJ Tw �+nu
raWON W
"04
Z'W S