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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 BEFORE BEGINNING WORK. <br /> 1.Name of each property owner: f <br /> Mailing Address: 15lo()TM, tVOi ity: OQ4P"O State:M^, Zip: <br /> Email Address: Phone: Fax: <br /> 2.Property Ow epresentative on-nation (not required)(licensed contracto ar ct,engineer,etc...) <br /> Business Name: Repr ,tative Name: t4 n1� �j— <br /> Business Address: City: .�,thy State: AAN Zip13VLW <br /> Email Address: hone: Fax: <br /> 3. Project Address: 1� � , City:d� <br /> State: ,/1,/ Zip: Qtr Section(s): Sectio (s): Township(s): Range(s): <br /> Lot: _Block: Subdivision: ) PID:2L fi <br /> T <br /> 4. Size of project parcel (square feet or acres): °1d- <br /> Area of disturbance(square feet): '01CO Vo mne of excavation/fill (cubic yards): ?—I— <br /> Area of existing impervious surface: C?j Wo-'3 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 ALTERATION ❑ STORMWATER MANAGEMENT <br /> ❑ WETLAND PROTECTION ❑ APPROPRIATIONS <br /> ❑ DREDGING ❑ ILLICIT DISCHARGE <br /> ❑ SHORELINE/STREAMBANK STABILIZATION <br /> 6.Project purpose(Check all that apply): <br /> M SINGLE FAMILY HOME ❑ MULTIFAMILY RESIDENTIAL(apartments) <br /> ❑ ROAD CONSTRUCTION ❑ COMMERCIAL or INSTITUTIONAL <br /> ❑ UTILITIES ❑ SUBDIVISIONS(include number of lots) <br /> ❑ DREDGING ❑ LANDSCAPING(pools,berms,etc.) <br /> ❑ SHORELINE/STREAMBANK STABILIZATION ❑ OTHER(DESCRIBE): <br /> 7.NPDES/SDS General Storrnwater Permit Number(if applicable): <br /> 8.Waterbody receiving runoff from site: <br /> 9.Project Timeline: Start Date: �' Completion Date: <br /> Permits have been applied for: City-10 County MN Pollution Control Agency DNR COE <br /> Permits have been received: City County MN Pollution Control Agency DNR COE <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 /> contai d in this application and,to the best of my knowledge and belief,all information is true,complete and accurate. I <br /> unde and that roceeding with work before all required authorizations are obtained may be subject to federal,state and/or local <br /> a ' s ive, 'vi d/or cruninal penalties. <br /> nature of Each Property O n Date <br /> I/2 55113 <br />