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WATER RESOURCE PERMIT APPLICATION FORM <br /> Use tlris 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 tlus form completely and submit with your site plan,maps,etc.to the MCWD at: <br /> 15320 Minnetonka Blvd.Minnetonlca,MN 55345. <br /> Keep a copy for your records. <br /> YOU MCTST OBTAIN ALL RE UIltED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1.Name of each prop ow� r: .�' <br /> Mailing Address -� Ci State: : Zip: <br /> Email Address: Phone: ' � Fax: <br /> 2. Properiy Owner Representative Information(not required) (licensed contractor, architect, engineer, etc...) <br /> Business Name: �SG Representative Name: Travis Fristed <br /> Business Address: 7900 International Drive,Su(te 550 Cl�,; Bloomington State: MN Zip: 55425 <br /> Email Address: travis.fristed@is-grp.com Phone: 952-426-0699 F�; <br /> 3. Project Address: 1205&1225 Shoreline Dr. Ci�; oror,o <br /> State: MN Zip: 55391 Q�Section(s}: sw Section(s): 2 Township(s): 117 Range(s): 23w <br /> Lot: Block: Subdivision: PID: 1011723130007, 1 01 1 7231 30006 <br /> 4. Size of project parcel (square feet or acres): 2.2o aores <br /> Area of disturbance(square feet): Not Applicable Volume of excavation/fill (cubic yards): Not Applicable <br /> Area of existing impervious surface: Not Applicable Area of proposed impervious surface: Not Applicable <br /> Length of shoreline affected(feet): N�A Waterbody(&bay if applicable): Not Applicable <br /> 5. Type of permit being applied for(Check a11 that apply): <br /> ❑ EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES <br /> ❑ FLOODPLAIN ALTERATION ❑ STORMWATER MANAGEMENT <br /> JB( WETLAND PROTECTION ❑ APPROPRIATIONS <br /> ❑ DREDGING ❑ ILLICTT DISCHARGE <br /> ❑ SHORELINE/STREAMBANK STABILIZATION <br /> 6. Project purpose(Check all that apply): <br /> ❑ SINGLE FAMILY HOME ❑ MLTLTI F�►MILY RESIDENTIAL(apartments) <br /> ❑ ROAD CONSTRUCTION ❑ COMIV�RCIAL or INSTTTiTTIONAL <br /> ❑ UTII,TTIES ❑ SUBDNISIONS (include number of lots) <br /> � DREDGING ❑ LANDSCAPING(pools,berms,etc.) <br /> ❑ SHORELINE/STREAMBANK STABII,IZATION � OTHER(DESCRIBE): Land Survey <br /> 7.NPDES/SDS General Stormwater Permit Number(if applicable): Not Applicable <br /> 8.Waterbody receiving runoff from site: Minnetonka <br /> 9. Project Timeline: Start Date: To Be Determined Completion Date: <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 acrivity will be conducted in compliance with these Rules.I am familiar with the informarion <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 are obtained may be subject to federal,state and/or local <br /> adminis c' il and/or c ' ' enalties. <br /> ! � ��� � /� <br /> Signature of E roperty Owner � Date <br /> lj.�v�;i(;r:i 7/i.:�/�i.:� �1%l��t;'. ( (}j' � <br />