Laserfiche WebLink
l.�.__._�,------ <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 OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1. Name of each property owner: ,��,- � ,����c- <br /> Mailing Address: %Z z y ,��l.fi� ��2� ��� City:� G'���,J� State: .t%k.�' Zip:,�.��`t� <br /> Email Address: �=�'; . f�`<<.�4� �/,��zs�y�j���. ���. Phone: �iz -��(��-�;3 7 y 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: z :�.`�.,,z S:�-4�� City: C>,2-o,.;c� <br /> State: /�9,�'' Zip: ,S 3'��� Qtr Section(s): Section(s): Township(s): Range(s): <br /> Lot: 1�����lock: �� Subdivision: /61��„��;-�� ,g,�� � �'�cys%n��y PID:/�a ---/��-2�-�1 -UL��-( <br /> 4. Size of project parcel (square feet or acres): �C�,,S c-'�' <br /> Area of disturbance (square feet): j,��; �� �� i- T. Volume of excavation/fill (cubic yards): <br /> Area of existing impervious surface: Area of proposed impervious surface: <br /> Length of shoreline affected (feet): �u�,� Waterbody (& bay if applicable): ,���•�� � <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 PROTECTION ❑ APPROPRIATIONS <br /> ❑ DREDGING ❑ ILLICIT DISCHARGE <br /> ❑ SHORELINE/STREAMBANK STABILIZATION <br /> 6. Project purpose (Check all that apply): <br /> �j SINGLE FAMILY HOME ❑ MULTI FAMILY RESIDENTIAL (apartments) <br /> ❑ ROAD CONSTRUCTION ❑ COMMERCIAL or INSTITUTIONAL <br /> ❑ UTILITIES ❑ SUBDIVISIONS (include number of lots) <br /> ❑ DREDGING ❑ LANDSCAPING (pools, berms, etc.) <br /> ❑ SHORELINE/STREAMBANK STABILIZATION ❑ OTHER(DESCRIBE): � <br /> 7. NPDES/SDS General Stormwater Permit Number(if applicable): <br /> 8. Waterbody receiving runoff from site: <br /> 9. Project Timeline: Start Date: Completion Date: <br /> Permits have been applied for: City �County �MN Pollution Control Agency � DNR �COE � <br /> Permits have been received: City �County �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 m,y knowledge and belief, all information is true, complete and accurate. 1 <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 crimirial�penadti�s. <br /> �;`-, <br /> ,--�� J � <br /> ����. �� , � s <br /> Signature of Each Property��Owner Date <br /> ��s�� i`��� �;'1; � ; 1'.tt'�t 1 ��f' 1 <br />