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WATER RESOQRCE PERMIT APPLI�ATIQN FORM <br /> Use this form to notifylapply to the Minnehaha Creek Watershcd DisMct(MGWD}of a proposed projat or work which may fall within <br /> their jurisdiction.Fill out this fo�completely and submit with your site plan,maps,etc.to the MGWD at: <br /> 15324 Minnetonka Blvd.Minnotanka,MN 5i345. <br /> Keep a copy for your records. <br /> YOU MUST OBTAIN ALL RE UIRED AUTHORIZATI4NS BEFORE BEGINNING WORK. <br /> l.Nanne of each property owner: <br /> Mailing Address: 5top G�w'W��n E}.�►.. '�= Cit3': M.�.sc�(�s State:� Zip:,�'Sf-�- <br /> Email Address: S�s...,da,..,.,.�@ G�r,css+i-n.vl�' Phone: Fax: <br /> 2.Properiy Owner Repre �entative Information not required)(licensed contractor,architcct,engineer,etc...) <br /> Business Name: :� ,�r�uaE T�s�o�t-B+��rf� Representative Name:���S�Cc.rk.� <br /> Business Address;��_�3.l<�S � City: 4,I;s,r�.a���t State:�Zip: <br /> Email Address: ' . . t . Phone: q52�-�cP,lo-aSfo�'^'- Fa�c: <br /> 3.Project Address: Zo�fU ��e�. �'�;y-e_ City: t�RarJ'O <br /> State:�_ Zip: .�'�334�1 f Qtr Section(s): Section(s): Township(s): Range(s): <br /> Lot: 1�-t�) Block: Subdivision:•tQRR-�i`"��,�,ke M:�„�.fs,k.�PID: <br /> 4.Size of project parcel(square feet or acres): <br /> Area of disturlaance(squaze feet): Volume of excavation/fill(cubic yards): <br /> Area of existing impervious surface: Area of proposed impervious surface: <br /> Length of shoreline affected(feet): W�terbody(&bay if applicable): <br /> S.Type of permit being applied for(Chcck all that apply}: <br /> � EROSIOAT CONTROL � WATERBODY CR(3SSINGSlSTRUCTURES <br /> ❑ FLQODPLAIN ALTERATION ❑ ST�RIvTWATER MANAGEMENT <br /> 0 WETLAND PROTECTION � APPROPRIATIONS <br /> C! DREDGING ❑ ILLICIT DiSCHARGE <br /> 0 SHOREL1T�tIE/STREAN�ANK STABII,IZATION <br /> 6.Project pur�se(Check all that apply): <br /> � STNGLE FAMtLY HOME 0 MULTI FAMILY RESIDENT'IAL(apartments) <br /> ❑ ROAD CONSTRUCT[ON ❑ COMMERCIAL or INSTITUTIONAL <br /> ❑ UTILITIES ❑ SLTBDIVISIONS(include number of lots) <br /> � DREDGING ❑ LANDSCAPING(pools,berms,etc.) <br /> O SHORELINE/STREAMBANK STABILIZATION � OTHER(DESCRIBE): <br /> 7.N�'DE3/SDS General Stormwater Fermit Numbear(if pl�cable): <br /> 8.Waterbody receiving runoff from site: <br /> 9.Proj�t Timeline: Start Date: Completion Date: <br /> Pernuts have been applied for:City ounty MN Pollution Control Ager�oy DNR CDE <br /> Permits have t�en received: City—�County�MN Pollution Coritrot A ency��NR�COE� <br /> By signing belaw,I hereby request a pemut to authorize the activities described herein.I certify that I am familiar with MCWD <br /> Rules and that the proposed activity will be conducteci in compliance with thess Rules.I am familiar with tha information <br /> contained in this application and,to the best af my knowledge and belief,all information is true,comp�cte and accurate. I <br /> understand that p�ding with work before atl required suthoriaalions are obta'rned may be subject to federal,state and/or lacal <br /> admi ' ative,ci ' criminal penaities. , <br /> t'�t/�Z�tq <br /> Sign re of perty Owner Date <br /> � 15t,� � � U f5 � <br /> 1}. <br /> JUL 15 2016 °' <br /> ��1 <br /> �� <br />