5.f) Water Surface Structure Use Permit ApplicationRECEIVED
MAY ?. ")'2015
CITY OF SC DIA
Office wf the Sheriff
J
Commi#mt w to rE.9pBence
lARlliatn M. FkRton
Shmill
Dan SbM
Chid Deputy
APPLICATION FOR WATER SURFACE STRUCTURE USE PERMIT
To Place a rd"oy, or ether sirrehure on or in the Waters of this county psrs■■ni tt� MN R■1es 6110,1800
Address: Z10 Met..,;
sca-1: ", N1^,
R -Mail: a - -e o� v % a.: G • �-, `
J ��{ ` Mbar
Type of structure: Y" w' p SI,L 5 W'''" body or water. � e"r E L+.iG ¢ dales R uV►�
Permit req aimineuts: Applion I shalt—nttlin a oognprehm s i %,'c liability insurance policy in the smoamt Mg less than
three hundred thousznd dvllsrs ($300,090). Thepolicy Shall remsit in effect for the durxtirm of the elfrrtive dates. A
Certificate of Insurance resat be supplied to the Sheriff's Office with the permit application.
1 the tmdmigaed applicant, agme to hold harmless Washingw County tar any and all claims multing frau the structaue
shotified on this application.
1. Dingram of water svfate skowng placement or structure, indade the &wth or the w■kr ut the
location of the swactum.
2. Permit must be issued bcfDre struehtre is placed e■ or in the water.
3. Flumling rafts, s+rim buoys and mooring b,"I mast be placed betw0ta the psrinit holder's property
lines as tht y extend into The xrater. mese strneturea must be hithta too feet of tbore.
4 Sowture must display proper mrwetive material as dexribed in IVIN State Rule it 1/.1$00.
5. Permit number mail be displayed on the str ecturs using numbers that are at hast taro inches high
and a tontrastiug color to the area wbetu ibey are attuchW.
Q 'Water ski sWom courses mud water ski jumps must be approved annually by the Cify Caused or
Township Board where the course will be located, special restricdeaa MAY APp13% Slsla■a ce■rxss
awnat elt ed 900 kct in length and roust display the permit ouither on the end flraals_ Shdom
eourssa and ski jumps cannot be s naripttiunal haraard. Water ski jumps must be lighted during the
boors of darkness.
City/ToPffaship "reseatstrve printed name:
Sigeutere: —
Spature of Applicant:
Date-.�
Law Entownent Carole► • 15015 62nd Sincet North -- P.O. Bax 3801, 641h anter. Mirrteaota 65002-3801
Phone 551431).7000 - Fax a5143D-71109 - TTY: 661-4304246
unwr_w®5h�lon.ARyS
equet EmplWrnent OppoMmily I AMMatiue Ariion
111 .��0� GOwifa .(L�wnR wu.��ierl
N.t�.. ..�1 eT V •MG leek4L
C.4btG -x 2.5" /
L /
/ 5
/ �.v
i
PURL/C
ACCESS
15,
00
s -
C .,
N
x