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,, <br />FORM <br />Use this form to notify/apply to the Minnehaha Creek Watershed District (MCWD) ofa se proJec orwor w ·ch 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 />I. Name of each property owner: 7ZE.P/#W , L/077 <br />Mailing Address: ·400 · /-Jt..Ot/12. City: 0/ZIJNO §tate:_Mv Zip:§4/~ <br />Email Address: Phone: 9.SZ .2 10, l.,lB, 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: · (X) : >/JWt.//L ~l:.-City: _ _:O=---/l_a_Wi_;'()=-------- <br />State: /iN. Zip: !?54J(A Qtr Section(s): ___ Sec)i on(s): __ Township(s): __ Range(s): __ <br />Lot: J':{' Block: i Subdivision: )3/J{()Ull /.!_MIL PID: 0 8-/17 -7.3,~31 -bcoi <br />4 .Sizeofprojectparcel(squarefeetoracres): /Z ,?,c:f!) ,It&/£ 9!51,CJO =-<. <br />Area of disturbance ( square feet): / Z CO .v Volume of excavation/fill ( cubic yards): NS Q <br />Area of existing impervious surface: zq47 Area of proposed impervious surface::---·-'.,=------ <br />Length of shoreline affected (feet): ____ Waterbody ( & bay if applicable): LALJ::. tftw,;101,tr) -Nt)thl <br />5. Type of permit being applied for (Check all that apply): <br />~ EROSION CONTROL <br />~FLOODPLAIN ALTERATION <br />□ WETLAND PROTECTION <br />□ DREDGING <br />□ SHORELINE/STREAMBANK STABILIZATION <br />6. Project purpose (Check all that apply): <br />1)1. SINGLE FAMILY HOME <br />□ ROAD CONSTRUCTION <br />D WATERBODY CROSSINGS/STRUCTURES <br />□ STORMWATERMANAGEMENT <br />□ APPROPRIATIONS <br />□ ILLICIT DISCHARGE <br />□ MULTIFAMILY RESIDENTIAL (apartments) <br />□ 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 ')( g County □ l\1N Pollution Control Agency □ DNR □ COE □ <br />Permits have been received: City __ -_ County CJ l\1N Pollution Control Agency □ DNR ti 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 />3C E-i z, Jt,w t.o I s <br />Signature of Each Property Owner Date <br />Revised 7/15/13 P age I of I