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Print Form� <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 ar <br /> 15320 Minnetonka Blvd.Minnetonka,MN SS345. <br /> Keep a copy for your records. <br /> YOU MUST OBTAIN ALL REQUIRED AUTHURIZATIONS BEFORE BEGINNING WORK. <br /> 1. Name of each property owner: <br /> Mailing Address: 1410 Cherry Piace C�ty; Orono State: MN_ Z�P; 55391 <br /> Emai!Address: kevintorgerson@gmail.com Phone: 972-�9-60� Fax: <br /> 2. Property Owner Representative Information (not required) (licensed contractor, architect,engineer,etc...) <br /> Business Name: Stonewood, LLC Representative Name: Sven Gustafson <br /> Business Address: 153 Lake St. East. C�ty; Wayzata State: MN Z�p; 55391 <br /> Email Address: svenCstonewood.com Phone: 6�2-462-4000 Fax: <br /> 3. Project Address: 1410 Cherry Place City: Orono <br /> State: MN Zip: 5�91 Qtr Section(s): Section(s): Township(s): Range(s): <br /> Lot: Block: Subdivision: PID: 08-117-23-33-0081 <br /> 4. Size of project parcel (square feet or acres): 23,038 sq.ft. <br /> Area of disturbance (square feet): 5500 sq.ft. Volume of excavation/fill (cubic yards): <br /> Area of existing impervious surface: 4965 Area of proposed impervious surface: 4965 <br /> Lengtl�of shoreline affected (feet): � Waterbody(& bay if applicable): North Arm, Lake Minnetonka <br /> 5. Type of permit being applied for(Check all that apply): <br /> � EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES <br /> ❑ FLOODPLAIN ALTERATION O STORMWATER MANAGEMENT <br /> ❑ WETLAND PROTECTION ❑ APPROPRIATIONS <br /> ❑ DREDGING ❑ lLLICIT DISCHARGE <br /> 0 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 /> 0 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:North Arm Bay, Lake Minnetonka <br /> 9. Project Timeline: Start Date: 1�-1-14 Completion Date: 10-�-15 <br /> Permits have been applied for: City �County ❑MN Pollution Control Agency ❑DNR ❑COE ❑ <br /> Permits have been received: City—�County—�MN Poliution Control Agency-�DNR—�COE� <br /> By signing below,1 hereby request a permit to authorize the activities described herein. I certify that I am familiar with MCWD <br /> Rules and that the proposed activiry will be conducted in compliance with these Rules.l arn 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. 1 <br /> understand that proceeding with work before all required authorizations are obtained may be subject to federal,state and/or local <br /> admini tr tive,civi, � inal penalties. <br /> �L�- �9-- � <br /> Signatur Each Prope e Date <br /> ��e��ised 'I!1>���.i �'a�r ' �i� i <br />