2003-2004 - MCWD erosion control permit

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JUL-16-2004 10 51 P.02/04 Application for Permit Transfer Use this form to apply to the Minnehaha Creek Watershed District(MCWD)for proposed transfer of an existing MCWD Fast- Track Permit to a new property owner. Fill out this form completely and mall to MCWD, 16202 Minnetonka Blvd,Deephaven. MN 55391, with all required accompanying documents. Keep a copy for your records. For questions call (952)471-0590. Project informatio -: ( / I. Permit number: irj b I �t (example 03-001) 2. Project location: a. Address i(0 1....)a-i.-u41....)a-i.-u4iik:lA,) ��,� b. City c. Property TD # 2 �l.' 1/ 9 I-3 -L /r - New owner information: For the purposes of this form the"new owner"will refer to the person or party requesting the permit be transferred to them. Name(last,first, MI) Corriony Name Of applicable) 1 Y2/� / • (O i �/JI tIAA) v l C'Y+� �l,ll.' j x'1,1 15,, Address (Street, RFD, Box#, City, State.Zip) _ q,5 L - Y /- Il 70 Aix/)6417(0 Azj/5I• C0•^1 Phone Number(include area code)/Email Address (if available)/Fax Number(if available) 2. Have)Au received a copy of the MCWD approved erosion control plan from the existing owner? _YES NO 3. Have_you received from the existing owner and reviewed a fact sheet on Sediment and Erosion Control? VYES .-NO 4. Are all approved/required erosion and sediment control measures indicated on the MCWD approved erosion conA plan installed and functioning according to MCWD approved standards? YES NO Request inspection by MCWD Staffs 4-Please note that requesting an inspection by staff will delay transfer of permit process until after such dine that an inspection can be completed. Inspections typically occur within two weeks of receiving request. . 5. Will you be using the current MCWD approved erosion control plan for this permit? ✓YES NO'ir *Attach a copy of your signed and dated proposed erosion control plan if you answered NO. Permit will not be transferred until the new proposed erosion control plan has been approved by MCWD i staff_ 6. I understand that permit transfer is not complete until I have received a permit,and I hereby give permi sion CO the 1 existing owner to enter my !or/property for the purpose of erosion and sediment control repair/i • ' n in order to comply with the conditions of the permit until such time that permit transfer is complete. Inui91 7. I understand that submission of this application does not guarantee permit transfer and more information may be requested. I understand that not answering yes to any of the above questions may delay issuance of the new permit. I hereby certify that to the •-st of ray knowledge and belief all information contained in this document and accompanying attachments ar ../•.,complete,and accurate_ I am aware that there are significant penalties for submitting false info, .cion. /f . . r . w� ! ‘0'_1 New Owner Signat Date Page 1 of 2 TO 29b'd S3WOH 113HSNSZIS 896T90On6 85 :60 b90Z/90/L0