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<br /> 231
<br /> 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 fail 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: A/9,4/44/2 5 /.4,3.// _
<br /> Mailing Address: ..c 300 a.]:(4.(..al-0 4111 1)4L__. City: eb2 5)1 r, State: Zip;. 53,5 c-
<br /> Eznail Address: A/S#4 t4. ,5'uL ra ci , «.-v,. Phone:yS--,L 80G- fb'7 2-- Fax:
<br /> 2. Property Owner Representative Information (not required) (licensed contractor, archi tect, engineer,etc...)
<br /> Business Name: /416774,- ,•vcd�,s Representative Name: MAi ,/ ,t✓ry
<br /> Business Address:e7 (7.5)z.),:.r , A71 e ,ilz,f ` City: S",-7,44.c.,c, State:' `a Zip:5's`/17_
<br /> Email Address: ,, k a, 1 ' r.:)--w L ,r�,r-. Phone:4,.5/• `f9i�, /399 Fax: !l 9
<br /> 3. Project Address: ;, oz-14/41...,/-.41/-1.)/2 s _ _ City:_ 00P-c7)70
<br /> State: Zip: Qtr Section(s): _Section(s):_ Township(s): Range(s):
<br /> Lot: _Block:. Subdivision: PID:
<br /> 4. Size of project parcel (square feet or acres): a36,, s4, 54 i:::-T---
<br /> Area of disturbance(square feet): 14.9ez." ra4 Volume of excavation/fill (cubic yards): 100
<br /> Area of existing impervious surface: $15Y Area of proposed impervious surface: a19 t
<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 0 WATERBODY CROSSINGS/STRUCTURES
<br /> ❑ LOODPLAIN ALTERATION 0 STORMWATER MANAGEMENT
<br /> J WETLAND PROTECTION 0 APPROPRIATIONS
<br /> ❑ DREDGING 0 ILLICIT DISCHARGE
<br /> ❑ SHORELINE/STREAMBANK STABILIZATION
<br /> 6. Project purpose(Check all that apply):
<br /> ❑ SINGLE FAMILY HOME 0 MULTI FAMILY RESIDENTIAL(apartments)
<br /> O ROAD CONSTRUCTION 0 COMMERCIAL or INSTITUTIONAL
<br /> ❑ UTILITIES 0 SUBDIVISIONS (include number of lots)
<br /> O DREDGINGANDSCAPING (pools,berms, etc.)
<br /> ❑ SHORELINE/STREAMBANK STABILIZATION BOTHER(DESCRIBE):
<br /> 7.NPDES/SDS General Stormwater 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 ❑County ❑MN Pollution Control Agency ❑DNR ❑COE ❑
<br /> Permits have been received: City Li County`❑MN Pollution Control Agency U DNR U COE Li
<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,c'vI1'ari 'ir criminal pe .•'"
<br /> ��Iwor.re ...-- - _ orf" — _.------ -- --- 5 ; J
<br /> Sig 'tu of Eac roperty Owner Date
<br /> o o „
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<br /> TUN 01 2°15
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