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IT PC Exhibit G " <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 OBTAJN ALL REQUIRED At]THORIZATIONS BEFORE BEGINNING WORK . <br />1. Name of each property owner: <br />. <br />~7c,OH,,9,V /(, /-z..Li07T <br />Mailing Address: / 400 i?.tJU> tl/2 ~nv /lLJ City:. 0/2LJNO State:~ Zip:§ 4/ & <br />Email Address: Phone: 9$2 , 210 l ·Zl$ 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: I 4CtJ i/:1/JL.Ot.Ja_ ,t/ /J/Z/Z-/ LoFJ.t) City: 0/ZON() <br />State: HN. Zip: ~Ip Qtr ~e_ct}on(s): _ S~on(~): Township(s): Range(s): <br />Lot: L5" Block: l Subd1v1S1on: }3;:Jl/.)tJ/l '/7/llL PID: 08-11_7-'Z.3-3/ -bOOi <br />4. Size of project parcel (square feet or acres): IZ,la_te;; _f/1.3ov7 9.s~ < ~-a..u/c,t:{; <br />Area of disturbance (square feet): /ZCO Volume of excavation/fill ( cubic yards): /115" 0 <br />Area of existing impervious surface: zq47 Area of proposed impervious surface: · <br />Length of shoreline affected (feet): Waterbody ( & bay if applicable): LAKe N/~~ -Nu..J>I ~ 1 12A, <br />I <br />5. Type of permit being applied for (Check all that apply): <br />~ EROSION CONTROL D WATERBODY CROSSINGS/STRUCTURES <br />Ji(FLOODPLAlN ALTERATION D STORMWATERMANAGEMENT <br />D WETLAND PROTECTION D APPROPRIATIONS <br />D DREDGING D ILLICIT DISCHARGE <br />D SHORELINE/STREAMBANK STABILIZATION <br />6. Project purpose (Check all that apply): <br />f>I. SJNGLE FAMILY HOME D MULTIFAMILY RESIDENTIAL (apartments) <br />D ROAD CONSTRUCTION D C011MERCIAL or. INSTITUTIONAL <br />D UTILITIES D SUBDMSIONS (include number oflots) <br />D DREDGING -D LANDSCAPING (pools, benns, etc.) <br />D SHORELINE/STREAMBANK STABILIZATION D OTHER (DESCRIBE): <br />7. NPDES/SDS General Stormwater Permit Number (if applicable): <br />8. Waterbody receiving runoff from site: I LJ~ H!AFAE7l>WM -A/ty2,,,'?i /-l/2./'1 <br />9. Project Timeline: Start Date: ~ ZD/5' Completion Date: /--11'iMt-ZD/{.,p <br />Permits have been applied for: City X □ County □ :MN Pollution Control Agency □ DNR D COE □ <br />Permits have been received: City □ County □ :MN Pollution Control Agency □ DNR D COE Cl <br />\ <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 ofmy lmowledge 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 '"iC;; ~fil p-ti~-- <br />ZI Yo!:¥ z:o I s <br />Signature of Each Property Owner. Date <br />RECEIVED <br />-----Re,risecl77l5/1T _____ -----------------------page 1 orJAUG-03 2015 _________ ------·-----------·-----·--·--·-- <br />CITY OF ORONO # 3773