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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: Mary Schommer <br /> Mailing Address: 3635 Togo Road City: Wayzata State: MN <br /> Email Address: tigertily2246@aol.com Zip: 55391 <br /> Phone:�2-463x516 Fes: <br /> 2. Property Owner Representative Information(not required) (licensed contractor, architect, engineer, etc...) <br /> Business Name: ISG Representative Name: Lucas Mueller <br /> Business Address: 7900 International Drive, Suite 550 City: Bloomington State: MN Zip: 55425 <br /> Email Address: lucas.mueller@>is-grp.com Phone: 952-426-0699 Fax: <br /> 3. Project Address: 3635 Togo Road City: Wayzata <br /> State: MN Zip: 55391 Qtr Section(s): Section(s): 17 Township(s): 117N Range(s): 23W <br /> Lot: Block: Subdivision: PID: <br /> 4. Size of project parcel (square feet or acres): 2.4 Acres <br /> Area of disturbance(square feet): N/A Volume of excavation/fill(cubic yards):N/A <br /> Area of existing impervious surface: N/A Area of proposed impervious surface: N/A <br /> Length of shoreline affected (feet): N/A Waterbody(&bay if applicable): N/A <br /> 5. Type of permit being applied for(Check all that apply): <br /> ❑ EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES <br /> ❑ FLOODPLAIN ALTERATION ❑ STORMWATER MANAGEMENT <br /> S WETLAND PROTECTION ❑ APPROPRIATIONS <br /> O DREDGING ❑ ILLICIT DISCHARGE <br /> ❑ SHORELINE/STREAMBANK STABILIZATION <br /> 6. Project purpose(Check all that apply): <br /> ❑ SINGLE FAMILY HOME ❑ MULTI FAMILY 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 Stormwater Permit Number(if applicable): N/A <br /> 8. Waterbody receiving runoff from site: N/A <br /> 9. Project Timeline: Start Date: N/A Completion Date: N/A <br /> Permits have been applied for: City ❑County 0 MN Pollution Control Agency 13 DNR 13 COE Cl <br /> Permits have been received: City=County—n MN Pollution Control Agencyn DNR—M COE—M <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 proceeding with work before all required authorizations are obtained may be subject to federal,state and/or local <br /> administrative,civil and/or criminal penalties. <br /> 7L-4e4- Ce —2/ — /7 <br /> Signature of h Property Owner Date <br />