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Print Form I
<br /> WATER RESOURCE PERMIT APPLICATION FORM
<br /> Use this form to notify/apply to the Minnehaha Creek 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 Blvd.Minnetonka,MN 55345.
<br /> Keep a copy for your records.
<br /> YOU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFO' BEGINNING WORK.
<br /> 1. Name of each property owner: ie.. G I>�_ /-¢21
<br /> Mailing Address: Do/ 4 ./(4 c' S-/ • City: ,Q�. ? - ,,, ate%j2 r-Zip: c;--S-? "/
<br /> Email Address P,12,; )�'�6�i '�'��,,�;i,�? - one: ,,1- C` ax5' <77- .
<br /> 2. Property Owner Representative Information(not required)(licensed contractor, architect, engineer, etc...)
<br /> Business Name: o t�8 Ck.c ASP OC/A7'ES',,l,vc. Representative Name: /144/K S. CA/04-4 CRf
<br /> Business Address: yy_, ,V, e./;/4404<-;pt,vE City: Z', GAkr State: Zip: g53,56"
<br /> Email Address: /iark9f5)9ronb ergo croc. ccm Phone: 992-r73- Fax:95-2-'12.?-4/V35
<br /> 3. Project Address: 690 BRar.c%v ,Pf)Ap .0 City: ORO,vp
<br /> State: 14,t- Zip: 5-5356 Qtr Section(s): Section(s): 591 Township(s):j/R Range(s): 2
<br /> Lot: iv/a Block: ,t,/,l Subdivision: x..//A PID:„ y_„8_23-/2-000 7
<br /> 4. Size of project parcel(square feet or acres): 2y 37 r,c.
<br /> Area of disturbance(square feet): 7r Ac, (3os c co :s;1 Volume of excavation/fill (cubic yards):20,000 r c r
<br /> Area of existing impervious surface: 6,5 .sc•, Area of proposed impervious surface: 2.6/ tAc.
<br /> Length of shoreline affected(feet): ,v/,q Waterbody(&bay if applicable): Zat/G z A/<F
<br /> 5. Type of permit being applied for(Check all that apply):
<br /> )21 EROSION CONTROL 13(WATERBODY CROSSINGS/STRUCTURES
<br /> ❑ FLOODPLAIN ALTERATION 3Eit STORMWATER MANAGEMENT
<br /> JRI WETLAND PROTECTION 0 APPROPRIATIONS
<br /> ❑ DREDGING 0 ILLICIT DISCHARGE
<br /> ❑ SHORELINE/STREAMBANK STABILIZATION
<br /> 6. Project purpose(Check all that apply):
<br /> ❑ SINGLE FAMILY HOME 0 MULTI FAMILY RESIDENTIAL(apartments)
<br /> ROAD CONSTRUCTION 0 COMMERCIAL or INSTITUTIONAL
<br /> UTILITIES 5Rt SUBDIVISIONS(include number of lots) -7
<br /> ❑ DREDGING 0 LANDSCAPING(pools,berms,etc.)
<br /> ❑ SHORELINE/STREAMBANK STABILIZATION 0 OTHER(DESCRIBE):
<br /> 7.NPDES/SDS General Stormwater Permit Number(if applicable):
<br /> 8. Waterbody receiving runoff from site: z a,t/G Z,9) 6-•
<br /> 9. Project Timeline: Start Date: SPRi/. 20/9 Completion Date: A:44, cf 9
<br /> Permits have been applied for: City ®County 0 MN Pollution Control Agency [3 DNR 0 COE 0
<br /> Permits have been received: City MN Pollution Control Agency DNR—1 COE—D
<br /> By signing below,I hereby request a permit to authorize the activities 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 pr. eeding with work before all required authorizations are obtained may be subject to federal,state and/or local
<br /> administrative and or-cfi ninal penalties.
<br /> "Sil rat1l a ouch Property Owner Date
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