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, "� (� . t: <br /> � *^�`�'�,�� ����' <br /> . i � ��1��i'�� -� ' <br /> , � � <br /> WATER RESOLIRCE RMIT APPLICATION —COMBINED JOINT NOTIFICATION FORM <br /> Use this form to notify/apply to th Minnehaha Creek Watershed District(MCWD),their engineering consultants,and the DNR of a <br /> proposed project or work which m y fall within their jurisdiction. These agencies should advise you of their jurisdiction or permit <br /> requirements within ]0 days. Fill o t this form completely and mail with your site plan,maps, etc...to the MCWD, 18202 Minnetonka <br /> Boulevard,Deephaven,MN 5539 . Keep a copy for your records. <br /> YOU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1. Property Owner Name (Fir t, Last): Erhard Bruderer (Private Residence) <br /> Mailing Address: 3045 S ssex Road City: Long Lake State: MN Zip: 55356 <br /> Email Address: Phone: 952-470-4004 Fax: <br /> 2. Location of proposed proj t(Attach map with directions to site): <br /> Project Address: 3045 Su sex Road City: City of Orono <br /> Counry: Henne in Qtr Section(s): Section(s): Township(s): Range(s): <br /> Lot: Block: Subdivision: FOX BEND PID: 04-117-2'�-�2-002d <br /> 3. Size of site:4.86 acres 11 702 sf)Area of disturbance: 11,500 square feet, or .27 acres <br /> Volume of excavation (or ill): 100 cubic yards Length of shoreline affected: feet <br /> Area of existing impervio surface: Area of proposed impervious surface: <br /> 4. Type of permit being appli d for(Check all that apply): <br /> ❑ EROSION CONTROL � WETLAND ALTERATION <br /> 0 STORMWATER MANAG MEI�TT �WATERBODY CROSSING <br /> � FLOODPLAIN ALTERA ION � SHORELINE/STREAMBANK IMPROVEMENTS <br /> � DREDGING LA DSCAPE GRADING PRIVATE RESIDENCE <br /> � OTHER DESCRIBE ; Re ontouring a tennis court area, that has been removed. <br /> � ) Nat' ralized contours for rairie restoration. <br /> 5 Project Purpose (Check all'that apply): <br /> � SINGLE FAMILY HOME 0 MULTI FAMILY RESIDENTIAL HOUSING (apartments, etc.) <br /> ❑ COMMERCIAL CONSTR CTION �INSTITiJTIONAL CONSTRUCTION (churches, schools, etc.) <br /> ❑ ROAD CONSTRUCTION 0 SUBDNISIONS (include number of lots) <br /> � UTILITIES �LANDSCAPING (pools, berms, etc.) <br /> 0 DREDGING �SHORELINE STABILIZATION (lakescaping,bioengineering) <br /> ❑ OTHER(DESCRIBE): <br /> 6. NPDES/SDS General Sto water Permit number (if applicable): <br /> 7. Alternatives (Describe any other sites or methods that could be used to avoid or minimize impacts to water <br /> bodies to achieve the project urposed. Attach additional sheet if needed.) <br /> � 8. Project Timeline: Start D e: OCt 28, 2008 Completion Date: <br /> 9. Applicants Representative Licensed contractor, engineer, etc...) <br /> Business Name: Representative Name: <br /> Business Address: City: State: Zip: <br /> Email Address: Phone: Fax: <br /> 10. Names and addresses of joining property owners (Attach list if necessary): <br /> Permits have been applied: C ty� County � MN Pollution Control Agency_�DNR_�COE� � <br /> Permits have been received: ity County ❑ MN Pollution Control Agency ❑ DNR ❑ COE� <br /> I hereby notify the recipients of thi form of the project proposed herein and request I be advised of any permits or other <br /> determinations concerning this pro ect that I must obtain. I understand that proceeding with work before all required authorizations <br /> are obtained may be subject to Fed ral, State and/or local administrative,civil and/or criminal penalties. <br /> Signature of Property Owner Date <br /> �Page 1 of 2 <br />