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Ikt�:+s.x:.,.3 6 :...�.�.sh:.'�_w. <br /> ' ' . REC���/�D <br /> WATER RE90URCE PERMIT APPLICATION FORM - <br /> Use this form to notify/apply to the Minnehaha Creek Watershed District(MCWD)of a proposed project or work which may fall within <br /> their jurisdiction.Fill out this form completely and submit with your site plan,maps,etc.t��1�I���� <br /> 15320 Minnetonka Blvd.Minnetonka,MN 55345. <br /> Keep a copy for your records. <br /> YOU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1. Name of each property owner: Gretchen and Lyle Shaw <br /> Mailing Address: �001 Kingston Dr. Clty; Eden Prairie State: MN Zlp; 55346 <br /> EI11ail AddY� 9retchen.shawQprecision-inc.com Phone: 612-382-8270 F�; <br /> 2. Property Owner Representative Information(not required) (licensed contractor, architect, engineer, etc...) <br /> Business Name: Stonewood, LLC Representative Name: Tomar Jones <br /> Business Address: �53 E. Lake St. Clty; Wayzata State: MN Zip: 55391 <br /> E11'lail Addl'� tomarQstonewood.com Phone: 612-770-5231 F�; <br /> 3. Project Address: �750 Shadywood Rd. CiTy: Orono <br /> State: MN Zip; 55364 Qtr Section(s): Section(s): Township(s): Range(s): <br /> Lot: 16 Block: Subdivision: Shadywood pID: �7-��7-23-2�-002� <br /> 4. Size of project pazcel(square feet or acres): 10740 <br /> Area of disturbance (square feet): 8�o Volume of excavation/fill (cubic yards):35000 <br /> Area of existing impervious surface: 1816 Area of proposed impervious surface: 3179 <br /> Length of shoreline affected(feet): 62 Waterbody(&bay if applicable): Minnetonka/Crystal Bay <br /> 5. Type of permit being applied for(Check all that apply): <br /> � EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES <br /> ❑ FLOODPLAIN ALTERATION ❑ STORMWATER MANAGEMENT <br /> ❑ WETLAND PROTECTION ❑ APPROPRIATIONS <br /> ❑ DREDGING ❑ ILLICIT DISCHARGE <br /> ❑ SHORELINE/STREAMBANK STABILIZATION <br /> 6. Project purpose(Check all that apply): <br /> 0 SINGLE FAMILY HOME ❑ MLJLTI FAMILY RESIDENTIAL(apartments) <br /> ❑ ROAD CONSTRUCTION ❑ COMMERCIAL or INSTITUTIONAL <br /> O UTILITIES ❑ SUBDNISIONS(include number of lots) <br /> ❑ DREDGING ❑ LANDSCAPING(pools,berms,etc.) <br /> ❑ SHORELINE/STREAMBANK STABILIZ,ATION ❑ OTI-�ER(DESCRIBE): <br /> 7.NPDES/SDS General Stormwater Permit Number(if applicable): <br /> 8. Waterbody receiving runoff from site:Lake Minnetonka <br /> 9. Project Timeline: Start Date: March 20�7 Completion Date: March 2018 <br /> Permits have been applied for: City �County �MN Pollution Control Agency �DNR �COE � <br /> Permits have been received: City—�County�MN Pollution Control Agency–�DNR�COE—� <br /> By signing below, I hereby request a permit to authorize the activities described herein. I certify that I am familiar with MCWD <br /> Rules and that the proposed activity will be conducted in compliance with these Rules. I am familiaz with the information <br /> contained in this application and,to the best of my knowledge and belief,all information is true,complete and accurate. I <br /> understand that proceeding with work before all required authorizations aze obtained may be subject to federal,state and/or local <br /> administrativ civil and/or crimi 1 penalties. <br /> J � <br /> Signature o ach Property O er Date <br /> Revised 7/15/l 3 Page 1 of 1 <br />