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OCT-15-2007 11�16 P.03iO4 �� ' WATER RESOURCE PERMIT APPLZCATIO.K--COMBINED J�INT NOTIFICATION FOR1V� Use this form to notify/apply to the Minnehaha Clreek Wate[shed Disttict(MCWD),their cngineering consultants,and the DNR of a proposed project or work which may fall within their jurisdiccion.These ageneies should advise you of their jurisdiction or permit requiremenCs within 15 days.Fill out this forru completely and mail with your site plara,maps,etc,..to the MCWD, 18202 Minnetonka Boulevard,Deephaven,MN 55391.Ke�p a e�opy for your rccords_ YOU MUST OBTAIN ALL RE UIRED AUTHORIZATIONS l3E�ORE BEG�NNING WORK. 1.Property Owner Name(rirst,Last): DI�J Mailin�Address: City: Sta,te: Zip: Emai) Address: Phone: Fax: 2.Location of proposed project(Atl;ach map with directions to site): Project Address: %b�l� $ptfi/l�S �o%uf �t7 C;ty: ��iuo County: �� , Qtr Section(s): Section(s): Township s): Ran e(s): Lot: Hloc : Subdivision: PID: ��1� Z-� - -�ci j 3. Size of site: �`3,�QS �. . Area of excavation (or fill): ,��'7 sq ft,or acres Volume of excavation or fill : �� cubic ards Len th of shoreline aFfected: g feet 4. Typc of permit being applied for(Check all that apply): �c]EROSION CONTROL QVi/�TLAND AL'�'�Rr'�T10N ❑STORMWATER MANAGEMENT OWATERBODY CROSSING ❑FLOODPLAIN ALTERATION ❑ SHOR�LINE/S'i'R�,AMBANK IMPROVEMENTS ❑DREDGING ❑OTHER ESCRJ�E : 5. Project Purpose (Check all that apply): �SINGLE FAMILY HOME ❑MULTI FAMILY R�SIDENTIAL NOUSrNG(apartments,etc.) COMM�RCIAL CONSTRUCTION ❑ 1NSTITUTIONAL CONSTRUCTION (churches,schools,etc.) ❑ROAD CONSTRUCTION ❑ SUBDTVTSTONS(inoludc number of lots) ❑UTILITIES ❑ LANDSCAPING(pools,bertns, etc.) ❑DREDGING ❑ SHORELINE STABIL,('LAT10N(lakescaping,bioengineering) ❑ OTHER DESCRIBE : 6. Alternatives (Describe any other sites or methods that could be used ta �void or minimize impacts to water bodies to achieve the project purposcdl.Attach additional sheet if needed.) 7.Pro'ect Timeline Start Date: �, T (; � Com letian Date: - f 8. Applicants Repr�sentative (Licen.se contractor, engineer, etc...) _,_,. Business Naane: .ST0�.1(s'1•.1�� _�� _� Representative Name: �,4�N /O L�s`Ai0 Business Address: 4 City: � State:��Zip: 55 26 Email Address: �� Phone:�J,��-6�! �,3'�� Fax: jZ-� - 9.Names and addresses of adjoining property owners (Attach list if necessary) Permits have been a�plied: City County�MN Pollution Control A�encyODNR�COE� Permits have been received: Cit �Count OMN Pollution Control A enc �DNR COED I he[eby notify the recipients of this form of t'he project proposed herein and request I be advised of any pennits or other deterrninations co�cerning this project that I must obtain.I understand that proceeding with work before all required authorizations a[e obtained may be subject to Federal,State.and/or local administrative,civil and/or crirninal penalties. Si nature of Pro e Owne� Uat�; , " �. ,.: �� � �D1 �::. � � u page 1 of Z ,C� ,� ��D�� . Jµ