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I��CEIVED <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 o�.yyqr�,���1�ithin <br /> their jurisdiction.Fill out this form completely and submit with your site plan,maps,etc.to tkL�11R� <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: �C�c���,,h,,,�,r, <br /> Mailing Address: Slvo G�_�,� S City: /�tMi4,«,,,,n(1 S State: 1�i Zip: e,FL� <br /> Email Address: .5„sa., c�w.,.,,r,..r, Q Cvf„c,r.s�-n� Phone: Fax: <br /> 2. Property Owner Repre enta.tive Informatio�not required) (licensed contractor, architect,engineer,etc...) <br /> Business Name: " �n t�r" Representative Name:�.i-ic,l� �.S-4,rc.a�c.1i <br /> Business Address: �. q,� �. City: d,/;�.,�,,n�/�;r State: �Gtn� Zip: �' r� <br /> Email Address: ' l(G•Ga+�, Phone: ��-.c�c����-- Fax: <br /> 3. Project Address: _Zp�{p �>�S +�„-e_ City: �rt.pnrQ <br /> State: ll�. � Zip:�'�'-��_Qtr Section(s): Section(s): Townslup(s): Range(s): <br /> Lot: 14- Iq Block: Subdivision:•`p pa,rk oN 4kt M�ww�erk�.PID: <br /> 4. Size of project parcel (square feet or acres): <br /> Area of disturbance(square feet): Volume of excavation/fill(cubic yards}: <br /> Area of existing impervious surface: Area of proposed impervious surface: <br /> Length of shoreline affected (feet): Waterbody(&bay if applicable): <br /> 5. Type of permit being applied for(Check all that apply): <br /> '� EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES <br /> ❑ FLOODPLAIN ALTERAT'ION ❑ 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 ❑ MIJLTI FAMILY RESIDENTIAL(apartments) <br /> ❑ ROAD CONSTRUCTION ❑ COMMERCIAL or INSTITUTIONAL <br /> ❑ UTILITIES ❑ SUBDNISIONS(include nurnber of lots) <br /> ❑ DREDGING ❑ LANDSCAPING(pools,berms,etc.) <br /> ❑ SHORELINE/STREAMBANK STABILIZATION ❑ OTI�R(DESCRIBE): <br /> 7.NPDES/SDS General Stormwater Permit Number(if applicable): <br /> 8. Waterbody receiving runoff from site: <br /> 9. Project Timeiine: Start Date: Completion Date: <br /> Permits have been applied for: City ounty ❑MN Pollution Control Agency ❑DNR ❑COE ❑ <br /> Permits have been received: City—D County�MN Pollution Control Agency�DNR�COE—� <br /> By signing below,I hereby request a permit to authorize the activiries 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 information is true,complete and accurate. I <br /> understand that proceeding with work before all required authoriza.tions aze obta.ined may be subject to federal,state and/or local <br /> admi ' �ative,ci ' r criminal penalties. <br /> e�i/�Zrl q <br /> Signa of E roperty Owner Date <br />