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. � ' , <br /> . � 3 <br /> WATER RFSOURCE PERMIT APPLICATION FORM <br /> Use this form to notify/apply to the Min�haha G+eek Wat�rshcd District(MGWD)of a proposed project or work which msy falt within <br /> tl�eir jurisdzction.Fill out this fam comptetely and submit with your site pls�,maps,etc.to tl�c MGWD ar. � <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: <br /> Mailing Address: 5t� G�rw't..�nn A.�,.g� 5 City: n.e.:...��,.(�s State:� Zip:g� <br /> Em�il Address: 5���.,d'.....,..�Q t�cs�s�--n,e►�f'' Phone; Fax: <br /> 2.Property Owner Repre entative Ix�formation not requir�d)(licensed cantracior,architect,engineer,etc...) <br /> i <br /> Business Name: " � � td+rf Representarive Name:�ic�-�S-4�rc.r4c-1� <br /> Business Address:�2 4►i.(���se�: City: ���,�r t�s r� 3tate:�Zip:� <br /> Emall Address: l Phone:��2-�bto-a*.;�lo"�t--- Fax; � <br /> . <br /> � <br /> 3.Project Address:�5�;�: �,..e_ City: t'�Rapn�O � <br /> State:l�� Zip �53e�! t Qtr Section(s): Section(s): Townshi�s): Range(s) <br /> Lot: It�-N'� Block: Subdivision:�*�-Yo�r��N}� ��PID: <br /> 4.Size of project parcel(squaze feet or acres}: ¥ <br /> Area of disturh�e(square feet): Volume of excavatian/fill(cubic yards): � <br /> Area of existing impervious surface: Area of proposed impervious suzface; � <br /> Length of shoreline affected(feet): Waterbody(&bay if applicable): � <br /> 5.Type of perniit boing applied for{Check all that apply): � <br /> $ EROSION CONTROL O WATERBODY CROSSR+tGS/STRUGTURES <br /> � FLOODPI.AIN ALTERATION O STORMWATER MANAGEMENT � <br /> ❑ WETLAND PROTECTIpN O APPROPRIATIONS " <br /> ❑ DREDGiNG ❑ ILLICIT DiSCHARGE � <br /> � <br /> 0 SHOREI.INE/STREAMBANK STABILIZATI4N � <br /> 6.Project purpose(Check a11 that�pp1y): a <br /> $ SINGLE FAMILY HOME ❑ MULTI FAMILY RESIDENTIAL(apartments) <br /> ❑ ROAD C�NSTRUCTION ❑ COMMERCIAL or II*iSTIT'UTIONAL <br /> p �Il,�g O SUBDNISiONS(inciude number of lots) ; <br /> O DREDGING O LANDSCAPING(pools,berms,etc.) � <br /> ❑ S�ORELINEISTREAMBANK STABIL�IZAT[ON ❑ OTHER(DBSCRIBE�: � <br /> 7.NPDES/SDS General Stormwater Permit Nucnber(zf a lic�ble): <br /> 8.Waterbody receiving nmoff from site: _ <br /> 9.Pro,ject Timeline: Start Date: Completion Date: s <br /> ; <br /> Permits have been applied for:City ounty MN Follution Control Agency DNR COE ; <br /> Permits have been received: City—�Counry�MAI Pollution Cantrol Agency—�DNR�COE� j <br /> By signing below,I hereby request a permit to authorize the activities described herein.I certit�that I am familiar with MCWD ; <br /> Rules and that the proposed activity wiU be conducted in compliance with these Rutes.I am famitiar with the informatic�n 3 <br /> contained in this appiication and,to the best of my knowledge and ixlief,all informatian is true,complete and accurate. I ', <br /> understand that procceding with work befarv all requir�etl suthorizations are obtained may be subject to federal,state and/nr local ' <br /> admi ' ative,ci ' r criminal penalties. <br /> ��1���� <br /> 9ign re of peRy Owrter Dste <br /> ��----. <br /> � � �j � � � t� � <br /> JU� 15 2U16 ��{ <br /> Ri <br /> G� <br />