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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 A1JTHORIZATIONS BEFORE BEGINNING WORK. <br />1. Name of each property owner: · _ ~TE-,,0~ /{, ftuor, <br />Mailing Address: /400 i?,::JU>t.1/2.. /Lanv /2.o City: CJMNO State:.M_v Zip:§4/& <br />Email Address: Phone:~ 1210,·~ 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 4(t) 1':l:i/JUJtJll. /.,) /J/11& // /',,ul City: 0/lOAlt) <br />State: /iAlo Zip: e:;;-~& Qtr Section(s): S~on(s): Township( s ): Range(s): <br />Lot: L-5" Block: l Subdivision: j3J:]&Jt/ ll. '/7/liL PID: 08-/L7 --Z.3-3/ -oooi <br />4. Size of project parcel (square feet or acres): IZ,l3_c6 _&eov7 9'.s~ <~, c.u/t.,d, <br />Area of disturbance (square feet): /ZCO Volume of excavation/fill (cubic yards): N5'" 0 <br />Area of existing impervious surface: <br />Length of shoreline affected (feet): <br />Z94"J_ Area of proposed impervious surface: · <br />Waterbody ( & bay if applicable): f.AKe ~/~ -/jjty,.J# ~ ~· <br />5. Type of permit being applied for (Check all that apply): <br />~ EROSION CONTROL □ WATERBODY CROSSINGS/STRUCTURES <br />~FLOODPLAIN ALTERATION □ STORMWATERMANAGEJ\IBNT <br />□ WETLAND PROTECTION □ APPROPRIATIONS <br />□ DREDGING □ ILLICIT DISCHARGE <br />□ SHORELINE/STREAl'v1BANK STABILIZATION <br />6. Project purpose (Check all that apply): <br />l}l SINGLE FAMILY HOJ\IB □ MULTIFAMILY RESIDENTIAL (apartments) <br />□ ROAD CONSTRUCTION □ CO:MIV.!ERCIAL or. INSTITUTIONAL <br />□ UTILITIES □ SUBDMSIONS (include number oflots) <br />□ DREDGING -□ LANDSCAPING (pools, benns, etc.) <br />□ SHORELINE/STREAl'v1BANK STABILIZATION □ OTHER (DESCRIBE): <br />7. NPDES/SDS General Stormwater Permit Number (if applicable): <br />8. Waterbody receiving runoff from site: I LJz; H!N,A~7l;;(;;)£/,J -A/u--J.iJJ ;/J/2/V/ <br />9. Project Timeline: Start Date: ~ ZO/£' Completion Date: ~t.-zoJ~ <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 □ COE CI <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 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 ''~t!:3 £ ~m P•-~--z.1 Yo!:¥ Z:D Is <br />Signature ofEach Property Owner. Date <br />RECEIVED <br />----Re'\ifaeQ77l57n-------------------------·------Pagel of lAUG-0.'3-20 15 ----------------------------------------------- <br />CllY OF OR~No # 3773