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WATER RESOURCE PERMIT APPLiCATION FORM <br /> Use this form to notify/apply to the Minnehaha Creek Watershed District(MCWD)ora prop�sed project or work which muy fall within <br /> their jurisdiction. Fill out this form complctcly and submit with your sitc plan,maps, ctc. to thc MCWD at: <br /> 15320 Minnctonka Bivd.Minnetonka,MN 55345. <br /> Keep a copy for your records. <br /> � YOU MUST OBTAIN ALL REQUIRFD AUTHORIZATIONS BEFORE BEGiNNING WORK. <br /> 1. Name of each property owner: I L �� ��, t- /i ., � F ,, �. <br /> MailingAddress: /� C- �� j� /ct.c'� (' l'�t� ,(� City: �`_- h4�fr� State: I7��c Zip: -s i <br /> Email Address: y� � n��� /., � �i c.� 1 _. �c�i�� Phonei��Z_31 i' -� �c C> Fa�c:95�% - 7�3- z � i Z <br /> 2. Property Owner Representative Information (not rcquired) (licensed contractor, architect, engineer, etc...) <br /> Business Name: �s� Representative Name: T�a��s F�+scea <br /> Busit]ess AddCess: �900 Intemational Drive,Suite 550 Clt}�: B�oomington State: MN Zlp: 55425 <br /> Email Address: tra��s.rr�s�ed@�s-g�p.com Phone: ss2-a2s-osss Fax: <br /> 3. Project Address: 252s,2535,and 2545 Shadywood Road Cjty; Orono <br /> State: MN Zjp; 55331 Qtr Section(s): NE Section(s): 20 Township(s): ��� Range(s): 23'^� <br /> Lot: Block: Subdivision: plp: 2o���2si�ooso,2oi�ns>>oozs, <br /> 2011723110028 <br /> 4. Size of project parcel (square feet or acres): 3.s�ac�e5 <br /> Area of disturbance(square feet): No�APPi'cabie Volume of excavation/fill (cubic yards): Noc APProabie <br /> Area of existing impervious surface: Nor,apPr�bie Area of proposed impervious surface: No�APpr�abie <br /> Length of shoreline affected (feet}: N�A Waterbody (& bay if applicable): "o�APPr�bie <br /> 5. Type of permit being applied for(Check all that apply): <br /> ❑ EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES <br /> ❑ FLOODPLAIN ALTERATION ❑ STORMWATER MANAGEMEN�' <br /> �( WETLAND PROTECTiON ❑ APPROPRtATIONS <br /> � DREDGING ❑ [LUC1T DISCHARGE <br /> � SHORELiNE/STREAMBANK STABiLIZATION <br /> 6. Project purpose (Check all that apply): <br /> ❑ SINGLE FAMILY HOME ❑ MULTI �AMILY RESfDENTIAL (apartments) <br /> ❑ ROAD CONSTRUCTION ❑ COMM�RCIAL or INSTITUTIONAL <br /> ❑ UT1LI�'IES ❑ SUBDIVISIONS (include number of lots) <br /> ❑ DREDGING ❑ LANDSCAPING(pools, berms, etc.) <br /> ❑ SHORELINE/STREAMBANK STABILIZATION � oTIiER (DESCRBE): Land Survey <br /> 7. NPDES/SDS General Stormwater Permit Number (if applicable): No�APPi��abie <br /> 8. Waterbody receiving runoff from site: u^k�oW� <br /> 9. Project Timeline: Starl Date: To Be oe�ermined Completion Date: <br /> Permils have been applied for: City County MN Pollution Control Agency DNR COE <br /> Permits have been received: City County MN Poilution Control Agency DNR COE <br /> By signing bclow,1 hcrcby rcqucst a permit to authorizc thc activitics dcscribcd hcrcin. I ccnify that I am familiar with MCV1'D <br /> Rules and that the proposed activity will be conducted in compliance wid�these Rules. I am familiar with the information <br /> contained in this application and, to the best of my knowledge and bclicf, all inforn�ation is true,complete and accurate. 1 <br /> understand that proceeding with work before all reyuired authorizations are obtained may be subject to federal,state and/or local <br /> administrative,civil and/or criminal penalties. <br /> � h �,�� 7/7 /i� <br /> 'gnature of ch Prope Owner Datc <br />