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Print Form <br /> t LI OW Form <br /> . <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 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: Dielan, LLC <br /> Mailing Address: 1060 Tonkawa Road City: Orono State: MN Zip: 55356 <br /> Email Address: dielanllc@gmail.com Phone: 612-518-1015 Fax: <br /> 2. Property Owner Representative Information (not required) (licensed contractor, architect, engineer, etc...) <br /> Business Name: Water Street Homes, LLC Representative Name: Rick Carlson <br /> Business Address: 1161 Wayzata Blvd. E. #208 City: Wayzata State: MN Zip: 55391 <br /> Email Address: rick@waterstreethomes.com Phone: 612-850-4002 Fax: <br /> 3. Project Address: 1060 Tonkawa Road City: Orono <br /> State: MN Zip: 55356 Qtr Section(s): Section(s): Township(s): Range(s): <br /> Lot: 1 Block: 1 Subdivision: Ryanwood PID: <br /> 4. Size of project parcel (square feet or acres): 61,960 <br /> Area of disturbance (square feet): 6,000 Volume of excavation/fill (cubic yards):30 <br /> Area of existing impervious surface: 8,526 Area of proposed impervious surface: 13,922 <br /> Length of shoreline affected (feet): 141' Waterbody(& bay if applicable): Maxwell Bay, Lake Mtka <br /> 5. Type of permit being applied for(Check all that apply): <br /> 121 EROSION CONTROL 0 WATERBODY CROSSINGS/STRUCTURES <br /> 0 FLOODPLAIN ALTERATION 0 STORMWATER MANAGEMENT <br /> 0 WETLAND PROTECTION 0 APPROPRIATIONS <br /> O DREDGING 0 ILLICIT DISCHARGE <br /> O SHORELINE/STREAMBANK STABILIZATION <br /> 6. Project purpose (Check all that apply): <br /> O SINGLE FAMILY HOME 0 MULTI FAMILY RESIDENTIAL(apartments) <br /> 0 ROAD CONSTRUCTION 0 COMMERCIAL or INSTITUTIONAL <br /> O UTILITIES 0 SUBDIVISIONS (include number of lots) <br /> ❑ DREDGING E LANDSCAPING(pools, berms, etc.) <br /> O SHORELINE/STREAMBANK STABILIZATION ❑ OTHER(DESCRIBE): <br /> 7. NPDES/SDS General Stormwater Permit Number(if applicable): <br /> 8. Waterbody receiving runoff from site:Lake Minnetonka <br /> 9. Project Timeline: Start Date: November 2014 Completion Date:June 2015 <br /> Permits have been applied for: City 0 County 0 MN Pollution Control Agency 0 DNR 0 COE El <br /> Permits have been received: City EI County—1:3 MN Pollution Control Agency DNR—D COE—El <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, civiland/ cri ' al penalties. <br /> /,/.Z <br /> Signature of Eac roperty Owner5at _ <br /> r uv X01 <br />