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. � • Ck ,1 �r-.� <br /> Y C.�L��I..�Y'�E� `.,� <br /> ���' - � ?�?�= <br /> C►TY OF ORONO <br /> WATER RESOURCE PERMIT APPLICATION FORM <br /> Use this form to notify/apply to the Minnehaha Crcek 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 Bivd.Minnetonka,MN 55345. <br /> Kecp a copy for your rccords. <br /> YOU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1. Name of each property owner: Patrick Butler <br /> Mailing Address: 3010 Somerset Lane C�ty. Orono State: MN Z�p; 55356 <br /> Email Address: butlerjillpat@aol.com Phone: 9�393 6695 Fax: <br /> 2. Property Owner Representative Information (not required) (licensed contractor, architect, engineer, etc...) <br /> Business Name: Anderson Engineering of MN,LLC Representative Name: Benjamin Hodapp <br /> Business Address: �3605 1st Ave N, Suite 100 C�ty. Plymouth State: MN Zip: 55441 <br /> Email Address: bhodapp@ae-mn.com Phone: 763 412 4000 Fax: �63 412 4090 <br /> 3. Project Address: 3010 Somerset Lane C��,: Orono <br /> State: MN Z�p; 55356 Qtr Section(s): SE Section(s): 4 Township(s): 117N Range(s): 23W <br /> Lot: � Block: 3 Subdivision: Old Crystal Bay Road 2nd Addn pip: 0411723220029 <br /> 4. Size of project parcel (square feet or acres):Approximately 3.45 acres <br /> Area of disturbance(square feet): N�A Volume of excavation/fill (cubic yards):N/A <br /> Area of existing impervious surface: N�A Area of proposed impervious surface: N/A <br /> Length of shoreline affected(feet): N�A Waterbody(&bay if applicable): N/A <br /> 5. Type of permit being applied for(Check all that apply): <br /> ❑ EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES <br /> ❑ FLOODPLAIN ALTERATION O STORMWATER MANAGEMENT <br /> 0 WETLAND PROTECTION ❑ APPROPRIATIONS <br /> ❑ DREDGING ❑ ILLICIT D]SCHARGE <br /> O SHORELINE/STREAMBANK STABILIZATION <br /> 6. Project purpose(Check all that apply): <br /> ❑ SINGLE FAMILY HOME O MULTI FAMILY RESIDENTIAL (apartrnents) <br /> ❑ ROAD CONSTRUCTION ❑ COMMERCIAL or II�STITUTIONAL <br /> � UTILITIES � SUBDIVISIONS(include number of lots) <br /> ❑ DREDGWG � LANDSCAPING (pools,bcrms,ctc.) <br /> O SHORELINEISTREAMBANK STABILIZATION � OTHER(DESCRIBE): Level 1 Delineation Review <br /> 7. NPDES/SDS General Stormwater Pern�it Number(if applicable):N/A <br /> 8. Waterbody receiving runoff from site:N/A <br /> 9. Project Timeline: Start Date: N�A Completion Date:N/A <br /> Permits have been applied for: City ❑County ❑MN Pollution Control Agency ❑DNR ❑COE ❑ <br /> Permits havc bcen reccivcd: City—�County-�MN Pollution Control Agency—�DNR—�COE—� <br /> By signing bclow,1 hereby request a permit to authorize the activitics described herein.I certify that 1 am familiar with MCWD <br /> Rules and that the proposed activity will be conducted in compliance with thesc Rules. t 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 accurate. 1 <br /> understand that proceeding with work before all required authorizations are obtained may be subject to federal,state and/or local <br /> administrative,civil and/ crimina)penaltics. <br /> � 2�% ` <br /> Signature of Each Propert wner Date ' <br /> R�°�•i�;ec? 7'l�'1� Pa;�e l oi� 1 <br />