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<br /> WATER RESOURCE PERMIT APPLICATION FORM
<br /> Use this form to notify/apply to the Minnehaha Geek 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 RE UIRED AUTHORIZATIONS BEFORE BEGINNING WORK.
<br /> 1. Name of each property owner: (��,�-����,,- 1 t�-twLb:-�-
<br /> Mailing Address: I��-�� �;G�e,fE� ,ti� Cit ��'a-:���. � �. 5���
<br /> y: State: �1� Zip:
<br /> Email Address: (�u:ti+t�L-s ��, ���r�,,,-:�.� 4 ;.�-�11; �:,.� �y ;.�.,�Phone: ir.iL�- �'��:.-?�"� 7 Fax:
<br /> 2. Property Owner,Representative Information (not reQuired) (licensed contractor, architect, engineer, etc...)
<br /> � � j �= �% Representative Name: .Sc���� .,��ti�,s�:--ti
<br /> Business Name: .+��c��l�-vT � c:z��..3� ,��N�U�������,
<br /> Business Address: y'��� �•��.,.-ks ,�,�.-�� City: �?,����G��;-4.,�G;,... State: �`J� Zip:;"5:�G>,�--
<br /> Email Address: > ri�- ��' 3,��';1��� t�e< - -: c_t:_-�.- Phone: �.,/�,,',��,-�//�S� Fax:
<br /> 3. Project Address: �'.s�C� ��.(,,�;,��, �'/r�_c-�. City: __���;�,�
<br /> State: ���� Zip: e._����,G/ Qtr Section(s}: Section(s): Township(s): Range(s):
<br /> Lot: .'-�L Block:� Subdivision: �-�L ��;1� %. -.,� PID: �?�;'r� 7� �.�'�:s'�'�`� ��_
<br /> 4. Size of project parcel (square feet or acres): ����=�r�c'_ �,���.
<br /> Area of disturbance (square feet): �,,.T����s�6-/-�— � Volume of excavation/fill (cubic yards): ��,
<br /> Area of existing impervious surface: ,S f5 i�, Area of proposed impervious surface: (�;,c� ��:.
<br /> Length of shoreline affected (feet): G Waterbody(&bay if applicable):
<br /> 5. Type of permit being applied for(Check all that apply):
<br /> �I 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 /> � 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: jr���,, ° . �.c`�; '" Completion Date: ��j�- ,;� ��=<<�—
<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 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 /> administrati , civil an or criminal penalties.
<br /> `i ,' � L' F�� � `L �� � �
<br /> Signature o Eac Property Owner Date
<br /> � ;r;��'�,i,+��, : r a: �. ��` � .,.
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