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Priniform <br /> WATER RESOURCE 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.to the MCWD at: <br /> 15320 Minnetonka Blvd.Minnetonka,MN 55345. <br /> Keep a copy for your records. <br /> YOU MUST OBTAIN ALL RE UIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1. Name of each property owner: �, a rYh � <br /> Mailing Address: 3 L S. City: M;nn �l�S State: �1 N Zip: SS ko 9 <br /> Email Address: 'ooa�,�o,,� Phone:f�l tL- Z L� Fax: -� <br /> 2. Property Owner Represeatative Information(not required)(licensed contractor,architect, engineer,etc...) <br /> Business Narne: Nor-son, Inc. Representative Name: Pat Schumacher <br /> Business Address: 700 East l.ake Street, Suite 213 City; Wayzata State: MN Zlp; 55391 <br /> Email Address: pat.schumacher@nor-son.com Phone: 952-767-7931 F�; <br /> 3. Project Address: 1760 Shoreline Drive City: Orono <br /> State: MN Zip: Qtr Section(s): Section(s): �� Township(s): y��N Range(s): 23N► <br /> Lot: Block: Subdivision: pID: 1 01 1 7231 4001 7 <br /> 4. Size of project parcel(square feet or acres): 4.02 Acres � <br /> Area of disturbance(square feet): TB� Volume of excavation/fill(cubic yards):TBD <br /> Area of existing impervious surface: N�A Area of proposed impervious surface: wA <br /> Length of shoreline affected(feet): N�A Waterbody(&bay if applicable): DNR wetland <br /> 5. Type of permit being applied for(Check all that apply); <br /> ❑ EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES <br /> ❑ FLOODPLAIN ALTERATION ❑ STORMWATER MANAGEMENT <br /> 0 WETLAND PROTECTION ❑ APPROPRIATIONS <br /> ❑ DREDGING ❑ ILLICIT DISCHARGE <br /> O SHORELINE/STREAMBANK STABILIZATION <br /> 6. Project purpose(Check all that apply): <br /> O SINGLE FAMILY HOME ❑ MULTI FAMILY RESIDENTIAL(apartments) <br /> ❑ ROAD CONSTRUCTION O COMMERCIAL or INSTITUTIONAL <br /> ❑ UTILITIES ❑ SUBDNISIONS(include number of lots) <br /> ❑ DREDGING ❑ LANDSCAPING(pools,berms,etc.) <br /> ❑ SHORELINE/STREAMBANK STABILIZATION � OTHER(DESCRIBE): <br /> 7.NPDES/SDS General Stormwater Permit Number(if applicable):N/A <br /> 8.Waterbody receiving runoff from site:N/A <br /> 9. Project Timeline: Start Date: �� Complerion Date:TBD <br /> Permits have been applied for: City �County �MN Pollution Control Agency �DNR �COE � <br /> Permits have been receiv�: City—�County—�MN Pollution Control Agency�DNR�COE—� <br /> By signing below,I hereby request a pernvt to suthorize 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 familiar with the information <br /> contained in this application and,to the best of my knowledge and belief,all informarion 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 /> admin' ative,civil an or eriminal penalries. <br /> o'�-I zy I z�t�- <br /> Si�na ure of ach Pro rty Owner Date <br /> [t.evise� ?/.15/13 Page 1 t�f 1 <br />