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, Print Form � � --- � WATER RESOURCE PERMIT APPLICATION FORM Use this form to notify/apply to the Minnehaha Creek Watershed District(MCWD)of a proposed project or work which may fall within their jurisdiction.Fill out this form completely and submit with your site plan,maps,etc.to the MCWD at: 15320 Minnetonka Blvd.Minnetonka,MN 55345. Keep a copy for your records. YOU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. 1.Name of each property owner: t (<� '`� Mailing Address: C < p, City: �r��41�State:�_ Zip:��q Email Address: -{-�Z�j`,��a S��ctc+[ . �-r w� Phone:��`]�,�jl� Fax: 2. Property Owner Representative lnformation (not required) (licensed contractor, architect, engineer, etc...) Business Name: � � Representative Name: Business Address: �' City: State: Zip: Email Address: Phone: Fax: 3. Project Address: ( � i �, a ; City: �Y�YL.C� State:_ {� t.� Zip: ��'' � ' Qtr Se tion(s): ��Section(s): 111 Township(s): '�Range(s): o� -6C t� Lot: Block: Subdivision: PID: - •a .�. _ c�<� 4. Size of project parcel (square feet or acres): r] Area of disturbance(square feet): � O� �.-�e�� Volume of excavation/fill (cubic yards): �. Area of existing impervious surface: U Area ofproposed impervious surface: (�Qp-�(p�� c�,#' �' Length of shoreline affected (feet): ►�c Waterbody(&bay if applicable): N 1 lk 5. Type of permit being applied for(Check all that apply): � EROSION CONTROL -r"j�; �-}- �� I�.,�� ❑ WATERBODY CROSSINGS/STRLJCTURES ❑ FLOODPLAIN ALTERATION ❑ STORMWATER MANAGEMENT ❑ WETLAND PROTECTION �~ Q�'e' ❑ APPROPRIATIONS ❑ DREDGING ❑ ILLICIT DISCHARGE ❑ SHORELINE/STREAMBANK STABILIZATION 6. Project purpose(Check all that apply): �,SINGLE FAMILY HOME O MULTI FAMILY RESIDENTIAL(apartments) ❑ ROAD CONSTRUCTION ❑ COMMERCIAL or INSTITUTIONAL ❑ UTILITIES ❑ SUBDIVISIONS(include number of lots) ❑ DREDGING ❑ LANDSCAPING(pools,berms, etc.) ❑ SHORELINE/STREAMBANK STABILIZATION O OTHER(DESCRIBE): 7. NPDES/SDS General Stormwater Permit Number(if applicable): 8. Waterbody receiving runoff from site: 9. Project Timeline: Start Date: �•�- �� Completion Date: 3� Permits have been applied for: City County ❑MN Pollution Control Agency ❑DN ❑COE ❑ Permits have been received: City County-�MN Pollution Control Agency—�DNR—�COE—� By signing below,I hereby request a pennit to authorize the activities described herein. I certify that I am familiar with MCWD Rules and that the proposed activity will be conducted in compliance with these Rules. I am familiar with the information contained in this application and,to the best of my knowledge and belief,all information is true,complete and accurate. I understand that proceeding with work before all required authorizations are obtained may be subject to federal,state and/or]ocal administrative ivil and/or criminal alties. ,� c � Signature h Property r Date �. Cu-�'� i,��•� ��x.i� I So;� �v b.e, �^�h1.ca�e� `�ar �trLc:Q, c� ` a U c�.-��.c�_ � CX`�,e�- �..Q_.c.�..