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� � � D 1 � � � LI 1�i �C � j , P�int F,o'r�n - <br /> � <br /> � JUL 2� 2015 <br /> WATER RESOURCE PERNIIT APPLICA i�T FORM <br /> Use this form to notify/apply to the M'innehaha Creek Watershed District(MCWD)of a se pro�ec•or wor c w ch may fa11 within <br /> their j�isdiction.Fill out this form completaly and submit with your sita plan,maps,etc.to the MCWD at: <br /> 153201Vrnnebonka.Blvd.Niinnetoaka,MN 55345. <br /> Reep a copy for your records. <br /> YOU NiLTST OBTAIN ALL RE UIl2ED AUTHORIZATIONS BEFORE BEGIlVNING WORK. <br /> 1.Name of each properiy owner: �t�if�.�+lf �O� <br /> Ma.iling Address: ��� Gp�//d, City: O/ZD/�O Sta.te: �Zip:;��'/t� <br /> Email Address: Phone:�,,r2 o ZJ�, Z�� Fax: <br /> 2.Properiy Owner Representative Information(not required)(licensed contractor,azchitect,engineer,etc...) <br /> Business Name: Representative Name: � <br /> Business Address: City: State: Zip: <br /> Email Address: Phone: Fax: <br /> 3.Project Address: fJr..,OG'/1. /t/�/` City: �'ct1/✓� <br /> Sta.te:,� Zip:�Qtr Sectio�n(s)• SecJ�on(s): Township(s): Range(s): <br /> Lot:�Block:�_Subdivision: f�rd/�/��iL PID: p�–//7–Z.�--�/ �t��ic�i <br /> 4. Size of project pazcel(squaze feet or acres): /Zr�Ci� � �t� ��9��p� _ � �t"=� ' � <br /> Area of disturbaace(square feet): jZ� Volume of excavation/fill(cubic yazds): /�//� � <br /> Area of exisbing impervious surface: Z„q�� Area of proposed impervious surface: � <br /> Length of shoreline affected(feet): Waterbody(&bay if applicable): � –/1l�i' /?.� <br /> 5.Type of permit being applied for(Check all that apply): <br /> �EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES <br /> �'FLOODPLAIN ALTERATION ❑ STORMWATER MANAGEMENT <br /> ❑ WETLAND PROTECTIQN ❑ APPROPRIATIONS <br /> ❑ DREDGING 0 ILLICTT IIISCHARGE <br /> ❑ SHORELINE/STREAMBANK 3TABILIZATION <br /> 6.Project purpose (Check a11 that apply): <br /> �SINGLE FAMII.Y HOME ❑ MULTI FANIII.Y RESIDEAiTTAi,(apartments) <br /> ❑ ROAD CONSTRUCTION ❑ COMMLRCIAI,or.INSTITUTIONAL <br /> p iTTII,TTIEs ❑ SUBDIVISIONS(include number of lots) <br /> ❑ DREDGING ❑ LANDSCAPING(pools,berms,etc.) <br /> ❑ SHORELIlVE/STREAMBANK STABILIZATION ❑ OTI�R(DESCRIBE): . <br /> 7.NPDES/SDS General5tormwater Permit Number(if applicable): <br /> 8.Waterbody receiving runofffrom site: ,tr �8a�,°� - �/.a/� <br /> 9.Project Timeline: Start Date: � �t�/S Completion Date: ` Z�/(o <br /> Permits have b�n applied for:City�County �MN Pollution Control Agency �DNR �COE � <br /> Permits hava been received: City County—�MN Pollution Control Agency—�DNR—�COE� , <br /> By signing below,I hereby request a permit to au�horize the activities described herein.I certify that I am familiar with MCR/D <br /> Rules and that the proposed activity will be conducted'm compliance with these Rules.I am familiar with the informa.tion <br /> contained in this application and,to the best of my lmowledge and belie�all infom�ation is true,complete and accurate. I <br /> undetstand that proceeding with work before all required suthoriza.tions aze obtainad may be subject to federal,state and/or local <br /> administraxive,civil and/or criminal penalties. <br /> � .5��.�� Z��v� �c��� <br /> Signatune of Each Properly Owner Date <br /> Revised 7/l5/13 Page 1 of l <br />