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WATER RESOURCE PERNIIT aPPLiCATI01�' FORM <br /> Use this fvrm to notifplapply to the �linnehaha Creek Watershed Uistrict(MCWD)ofa prop�sed project or work which may fall within <br /> their jurisdiction. Fill out this form complctcly and sub►nit with your sitc rlan,maps,ctc. to thc MCWU at: <br /> 15320 Minnctonka Blvd.Minnetonka,MN 55345. <br /> Keep a copy for yom•records. <br /> � YOU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1. Nan1e of each property owner: l � �/ ',c� �- /i � �� E � � <br /> Mailing Address: /S C �� f� 1 ti�-� C' /E +'� k City: C'__ l+� ����, State: /l�i�_.Zip: �� s - i <br /> Email Address: y��Q��r k, � �i�� 1 _, �e�:� Phone���l_31 F'�-1 =�� � Fax:i5��- 23 3 - 2 �i z_ <br /> 2. Property Owner Representative Infocmation (not required) (licensed contractor, architect, engineer, etc...) <br /> Business Name: �s� Representative Name: T�a��s Fr�sted <br /> BUSII]e5S AC1CIreSs: 7900 International Drive,Suite 550 Clty: Bloomington State: MN Zjp; 55425 <br /> E(IIaII A[ICII'eSS: travis.fristed@is-grp.com Phone: ss2-a2s-osss Fax: <br /> 3. Project Address: 25z5,2535,and 2545 Shadywood Road CICy: Orono <br /> State: MN Zjp: 55331 (,�tr SeCitOtt(S�: NE Section(s): 20 Township(s): ��� Range(s): 23w <br /> Lot: Block: Subdivision: PID: 2o>>ns��ooso.2011723110029, <br /> 2011723110028 <br /> 4. Size of project parcel (square feet or acres): 3.6�ac�es <br /> Area of disturbance (square feet): "o�aPPncabie Volume of excavation/fill (cubie yards): No�a�pi�canie <br /> Area of existing impervious surface: Nor a,PPr�abie �rea of proposed impervious surface: Noi appitcabie <br /> Length of shoreline affected (feet): N�A Waterbody(& bay if applicable): Not apPr�abie <br /> 5. Type of pennit being applied for(Check all that apply): <br /> ❑ EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES <br /> ❑ FLOODPLAIN ALTERATiON ❑ Sl'ORMWATER MANAGEMENT <br /> �( WETLAND PROTECTION ❑ APPROPR[ATIONS <br /> � DREDGING ❑ ILLICIT DISCHARGE <br /> ❑ SHORELTNE/STREAMBANK STABILIZATION <br /> 6. Project purpose (Check all that apply): <br /> ❑ SINGLE FAMILY HOME O MULTI FAMILY RES(DENTIAL(apartments) <br /> ❑ ROAD CONSTRUCTION ❑ COMMERCIAL or INSTITUTIONAL <br /> O UT1LI1'IES ❑ SUBDIVISInNS (include number of lots) <br /> ❑ DREDGING ❑ Lt1NDSCAPING(pools, berms,etc.) <br /> ❑ SHORELINE/STREAMBANK STABILIZATION � OTI�ER(DESCRtBE): Land Survey <br /> 7. NPDES/SDS General Stormwater Permit Number(if applicable): Not APPn�abte <br /> 8. Waterbody receiving runoff from site: u�k�own <br /> 9. Project Timeline: Starl Dale: To Be�eterm+��d Completion Date: <br /> Penni[s have been applied for: City County MN Pollution Control Agency DNR COE <br /> Permits have been received: Ciry County MN Pollution Control Agency DNR COE <br /> By signing bclow,1 hcrcby rcqucst a permit to authorizc thc activitics dcscribcd hcrcin. [ccrtify that 1 am familiar with MCWD <br /> Rules and that thc proposed activity will be conducced in compliance wid�tl�ese Rules. I am familiar with the information <br /> contained in this application and, to the best of my knowledgc and bclicf,all infonnation is true,complete and accurate. 1 <br /> understand that proceedinb with work before all required authorizations are obtained may be subject to federal,state and/or local <br /> administrative,civil and/or criminal penalties. <br /> � - , <br /> ��� ��'�� 7/7 /iG <br /> 'gnature of ch Prope Owner Datc <br />