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;.Prim Point <br /> WATER RESOURCE PERMIT APPLICATION-COMBINED JOINT NOTIFICATION FORM <br /> Use this form to notify/apply to the Minnehaha Creek Watershed District(MCWD),their engineering consultants,and the DNR of a <br /> proposed project or work which may fall within their jurisdiction.These agencies should advise you of their jurisdiction or permit <br /> requirements within 10 days.Fill out this form completely and mail with your site plan,maps,etc...to the MCWD,18202 Minnetonka <br /> Boulevard,Deephaven,MN 55391.Keep a copy for your records. <br /> YOU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1.Property Owner Name(First,Last): 41 p A TER V4.,V 0 O t4'S E K F- <br /> Mailing Address: o?4 7 S 5rwrp Vre" OR City: d>Roy o State: 1n1v Zip: S'5'3,S' <br /> Email Address: aha«da.m, vcanoucr ecce""."-Phone: - -z Fax: vo v <br /> 2.Location of proposed project(Attach map with directions to site): <br /> Project Address: R6 q 5 W4T1FR TOWnJ R6 City: IJRp v0 <br /> County: NtNNEP.r v Qtr Section(s): Section(s): Township(s): Range(s): <br /> Lot: I Block:_�Subdivision: OtD CAYSMt 84V RD PID: 0-/- t I?- 3- ! -000? <br /> 3.Size of site: R.5 4 Acte e S Area of disturbance: 4J/IA square feet,or . ?S acres <br /> Volume of excavation(or fill): o7o -,3,o cubic yards Length of shoreline affected: .v 1A feet <br /> Area of existing impervious surface: r✓ A Area of proposed impervious surface: in k4 <br /> 4.Type of permit being applied for(Check all that apply): <br /> 9EROSION CONTROL 0 WETLAND ALTERATION <br /> STORMWATERMANAGEMENT 0 WATERBODY CROSSING <br /> 0 FLOODPLAIN ALTERATION 0 SHORELINE/STREAMBANK IMPROVEMENTS <br /> 0 DREDGING <br /> 0 OTHER(DESCRIBE): <br /> 5.Project Purpose(Check all that apply): <br /> SINGLE FAMILY HOME 0 MULTI FAMILY RESIDENTIAL HOUSING(apartments,etc. <br /> COMMERCIAL CONSTRUCTION 0 INSTITUTIONAL CONSTRUCTION(churches,schools,etc.) <br /> 0 ROAD CONSTRUCTION 0 SUBDIVISIONS(include number of lots) <br /> 0 UTILITIES 0 LANDSCAPING(pools,berms,etc.) <br /> 0 DREDGING 0 SHORELINE STABILIZATION(lakescaping,bioengineering) <br /> 0 OTHER(DESCRIBE): <br /> 6.NPDES/SDS General Stormwater Permit number if applicable): AJIA <br /> 7.Alternatives(Describe any other sites or methods that could be used to avoid or minimize impacts to water <br /> bodies to achieve the project purposed.Attach additional sheet if needed.) ,vl,, <br /> 8.Project Timeline: StartDate: iD-.29-ao is Completion Date: S-- 30 - q o 1 3 <br /> 9.Applicants Representative(Licensed contractor,engineer,etc...) <br /> Business Name: CoQ Dov -TA*"JF S 60x.57• Representative Name: SrnE ✓h9C,0tV 'RS'd-c/ <br /> Business Address: PO Box 304, City: rr/oPtC [Arr✓ State: �N Zip: S-S3S9 <br /> Email Address: 'o c P oi-da, - owners. co"+Phone: '163 U74-3/!7 Fax: ?�3 y'29-3/�g <br /> 10.Names and addresses of adjoining property owners(Attach list if necessary): <br /> L�t4Y ?AR K &-ov orvf- S.}ibE — orto,,eR ,yffrGHBoK .dol- .Cwourx/ <br /> Permits have been applied: City County 0 MN Pollution Control Agency-DNR_ COED_ <br /> Permits have been received:City0 County © MN Pollution Control A enc 0 DNR 0 COE <br /> I hereby notify the recipients of this form of the project proposed herein and request I be advised of any permits or other <br /> determinations concerning this project that I must obtain.I understand that proceeding with work before all required authorizations <br /> are obtained may be subject to Federal,State and/or local administrative,civil and/or criminal penalties. <br /> Signature of Property Owner Date <br /> Pagel of 2 <br />