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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: r * Z 14 <br /> Mailing Address: /I 6,2A aE y: 61k A,yeZ-- State: A41V Zip: 637330 <br /> Email Address: of�2r.04._ g7@i% n. Gom Phone: QJ, Qo/. 7SPS Fax: <br /> 2. Property Owner Representative Information(not required) (licensed contractor, architect,engineer, etc...) <br /> Business Name: ..L�fa _ Representative Name: �ct� Noe!jt " <br /> Business Address: 79ya Z'h vnG a•�.d Q/- St4tc. City: M;nrw-y0a/..t State: AW Zip: dSyAr <br /> Email Address: Phone: 96'0. 9/.4 /,1$Y Fax: <br /> 3. Project Address: 3470 u a City: Orana <br /> State: 'AV Zip: 533 g r Q r Section(s): Seetion(s): 17 Township(s): /17 Range(s): �3 <br /> Lot: Block: Subdivision: PID: 171t7e7331003e? <br /> 4. Size of project parcel (square feet or acres): 0.1? cc et s <br /> Area of disturbance (square feet): ___A�A Volume of excavation/fill(cubic yards): AIA <br /> Area of existing impervious surface: —,AIA Area of proposed impervious surface: <br /> Length of shoreline affected(feet):__A(A—Waterbody(&bay if applicable): NA <br /> 5. Type of permit being applied for(Check all that apply): <br /> ❑ EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES <br /> ❑ FLOODPLAIN ALTERATION ❑ STORMWATER MANAGEMENT <br /> )K WETLAND PROTECTION ❑ APPROPRIATIONS <br /> ❑ 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 J? OTHER(DESCRIBE): <br /> 7. NPDES/SDS General Stormwater Permit Number(if applicable): A(A <br /> 8. Waterbody receiving runoff from site: <br /> 9. Project Timeline: Start Date: TID Completion Date: <br /> Permits have been applied for: City 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 /> 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 /> admipistrative ivil and/or criminal penalties! <br /> l i <br /> Signature of Eac P�� p�Owner Date <br />