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� <br /> ��� � <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 wi thin <br /> their jurisdiction.Fill out tlus form coinpletely 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 /> t.Name of each property owner: �ennepin County, Greg Moore <br /> Mailing Address: 300 South Sixth Street ���,: Minneapolis g��;MN Zip; 55487 <br /> Email Address: 9�egory.moore@hennepin.us pho��: (612)596-783d F�: <br /> 2. Property Owner Representative Inforrnation{not required){licensed contractox,archi#ect,engineer,etc.,.} <br /> Business Name: WSB&Assocfates, fnc. Representative Name:Tom Voll <br /> Business Address: 709 Xenla Ave S#300 City: Minneapolis State: MN Z�p;55416 <br /> Email Addl'ess:�all@wsbeng.com Phone: ��63)287-7175 F�: <br /> 3. Project Address: 3880 Shoreline Drive C��,; Orono <br /> State: MN Z�p; 55391 �Section(s}: Section{s): Township(s}: Range(s): <br /> Lot: Block: Subdivision: pID; 1711723330151 <br /> 4. Size of project parcel(square feet or acres): 6.43 acres <br /> Area of disturbance(square feet): �3068 sq ft Voiume of excavation/fili(cubic yards): <br /> Area of existing impervious surface: 3.14 acres �ea of proposed impervious surface: a <br /> Length of shoreline affected(feet): � Waterbody(&bay if applicable): <br /> 5.Type of permit being applied for{Check all that apply): <br /> 0 EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCT[JRES <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 /> ❑ SINGLE FAMILY HOME CJ.M[TLTI FAMII,Y RESIDENTIAL(apartments) <br /> ❑ ROAD CONSTRUCTION C�J COMNIERCIAL or INSTITUTIONAL <br /> 0 iJTILITIES ❑ SUBDNISIONS(include number of lots) <br /> ❑ DREDGING ❑ LANDSCAPWG(pools,berms,etc.) <br /> ❑ SHORELINE/STREAMBANK STABILIZATION ❑ OTI�R(DESCRIBE): <br /> 7.NPDES/SDS General Stormwater Permit Number(if applicable): <br /> 8.Waterbody receiving runofffrom site:Lake Minnetanka <br /> 9. Project Timeline: Start Date;April 2015 Completion Date: November 2015 <br /> Permits have been applied for:City 0 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 heroin.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 information is true,complete and acc�ate. I <br /> understand that proceeding with work before aIl required authorizations are obtained may be subject to federal,state and/or local <br /> administrative,civil and/or criminal penalties. <br /> �l v'�-e'Lt--. l't-• « � I 4� <br /> Signature of Each Property Owner Date <br /> Elc�iscil ?-I�`I � l'a��e I c,l� 1 <br />