Laserfiche WebLink
L.:'.) <br />Council <br />Exhibit D <br />WATER RESOURCE PERMIT APPLICAT <br />Use this form to notify/apply to the Minnehaha Creek Watershed District (MCWD) of a~!;;s~e ~p;;ro~~~ec~or~w::=:o;;r ~w~1ci'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 AUTIIORIZATIONS BEFORE BEGINNJNG WORK. <br />1. Name of each property owner: 721£~~ , UO I I <br />Mailing Address: ·400 ° /Jt.L>t/12.. City: C,MNO ,State: .M_v Zip: §4/i.,, <br />Email Address: Phone: 9.$2 ,210, U8> Fax: <br />2. Property Owner Representative Information (not required) (licensed contractor, architect, engineer, etc ... ) <br />Business Name: _____________ Representative Name:----------'---- <br />Business Address: _____________ City: ________ State: __ Zip: __ _ <br />Email Address: _____________ Phone: Fax:. _____ _ <br />3. Project Address: · CO : 't.L)()IL ~ City: _ _;;O;;__l'l_OM___;'()::;__ ____ _ <br />State: H111. Zip: 'f59JJ(A Qti Section(s): ___ Sec~on(s): __ Township(s): __ Range(s): -- <br />Lot: J-5' Block: / Subdivision: &Wt!ll /:!_h'liL PIO: 08-IJ7--z.&~3,/ -bcx'Jj <br />4.Sizeofprojectparcel(squarefeetoracres): /Z,3® ,&&¢ 951,00 =-<:::. <br />Area of disturbance (square feet): IZCO " Volume ofexcavation/fill (cubic yards): Nd"" 0 <br />Area of existing impervious surface: ZCJ47 Area of proposed impervious surface::---..,-'=------ <br />Length of shoreline affected (feet): ___ Waterbody ( & bay if applicable): LA.c.e tit~ -A/,:vl.»i <br />5. Type of permit being applied for (Check all that apply): <br />~ EROSION CONTROL <br />~FLOODPLAIN ALTERATION <br />□ WATERBODY CROSSINGS/STRUCTURES <br />□ STORMW ATER MANAGEMENT <br />□ WETLAND PROTECTION □ APPROPRIATIONS <br />□ DREDGING □ ILLICIT DISCHARGE <br />□ SHORELINE/STREAMBANK STABILIZATION <br />6. Project purpose (Check all that apply): <br />l)l. SINGLE FAMILY HOl\.ffi □ MULTIFAMILY RESIDENTIAL (apartments) <br />□ ROAD CONSTRUCTION □ COMMERCIAL or.INSTITUTIONAL <br />D UTILITIES □ SUBDMSIONS (include number oflots) <br />□ DREDGING □ LANDSCAPING (pools, berms, etc.) <br />□ SHORELINE/STREAMBANK STABILIZATION □ OTHER (DESCRIBE): <br />7. NPDES/SDS General Stormwater Permit Number (if applicable): <br />Permits have been applied for: City X g County □ MN Pollution Control Agency Cl DNR Cl COE C <br />Permits have been received: City __ County ti MN Pollution Control Agency □ DNR □ COE □ <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, civil and/or criminal penalties. <br />iC& ZI ;11.u.¥ t.o i s <br />Signature of Each Property Owner Date <br />Revised 7/15/13 Page I of l