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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: y ,t'e A,// 'n E a- <br /> Mailing Address: S(o 6-' /� /t4 ('� r I*e e e City: ( -/+q S Al'- State: )1iLL,Zip: S5_3/� <br /> Email Address: Pq c o til C k-1 �i CI,o I _ ec)N 1 Phone4,/2-31 P -S C, Fax:9S2-23 3 Z- i Z <br /> 2. Property Owner Representative Information (not required) (licensed contractor, architect, engineer, etc...) <br /> Business Name: ISG Representative Name: Travis Fristed <br /> Business Address: 7900 International Drive,Suite 550 City: Bloomington State: MN Zip: 55425 <br /> Email Address: trovis.tristed@is-9rp.com Phone: 952-426-0699 Fax: <br /> 3. Project Address: 2525,2535,and 2545 Shadywood Road City: Orono <br /> State: MN Zip: 55331 Qtr Section(s): NE Section(s): 20 Township(s): 117 Range(s): 23W <br /> Lot: Block: Subdivision: PiD: 2011723110030,2011723110029, <br /> 2011723110028 <br /> 4. Size of project parcel (square feet or acres): 3.67 acres <br /> Area of disturbance(square feet): Not Applicable Volume of excavation/till (cubic yards):Not Applicable <br /> Area of existing impervious surface: Not Applicable Area of proposed impervious surface: Not Applicable <br /> Length of shoreline affected (feet): NIA Waterbody(& bay if applicable): Not Applicable <br /> 5. Type of pen-nit being applied for(Check all that apply): <br /> ❑ EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES <br /> ❑ FLOODPLAIN ALTERATION ❑ STORMWATER MANAGEMENT <br /> X WETLAND PROTECTION ❑ APPROPRIATIONS <br /> ❑ DREDGING ❑ ILLICIT DISCHARGE <br /> ❑ SHORELINE/STREAMBANK STABILIZATION <br /> 6. Project purpose(Check all that apply). <br /> ❑ 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 X OTHER(DESCRIBE): Land Survey <br /> 7.NPDES/SDS General Stormwater Permit Number(if applicable): Not Applicable <br /> 8. Waterbody receiving runoff from site: Unknown <br /> 9. Project Timeline: Start Date: To Be Determined 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,1 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 /> Uaw 7/7 /ie- <br /> f ch Prope Owner Date <br />