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i S� i <br /> Print Form <br /> WATER RESOI3RCE PERMIT APPLICATION FORM <br /> Use this form to notify/apply to the Minnehaha Creek Watershed District(MCWD)of a proposed project or work which rnay fall wifhin <br /> their jurisdiction.Fill out zhis fom�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�LL REQUTRED AUTHORILATIONS BEFORE BEGINNING WURIC. <br /> 1.Name of each property owner: Steve and Anpefa Lisles <br /> Mailing Address: �60 Birch Lane Ci�y. Orono State: NiN Zip: 55391� <br /> Email Address: Phone: Fa�c <br /> 2.Property Owner Representative Infnrmation(not required)(licensed contractor,architect,engineer,etc...) <br /> Business Name: M 8�M Home Contractors,Inc. Representative Name: tilike Fritz <br /> Business Address: PD Box 90 Cjty; Cologne State: MN Zip: 55322 <br /> _ Fax: <br /> Email Address: mfrifz@mandmquality.com Phone: 612-554-2556 <br /> 3.Project Address: 3460 Birch Lane � C�ty; Orono <br /> State: �� Zip: 55391 Qtr Section(s): Section(s): Township(s): Range(s): <br /> Lot: P��9 Block: Subdivision: Lydiard's Park PID: <br /> 4.Size of project pareel(square feet or acres): 18847 sq ft <br /> Area of disturbance(square feet): ,,�''` Volume of excavation/fill(cubic yards� <br /> Area of existing impervious surface:�LL Area of proposed impervious surface: _% <br /> Length of shoreline affected(feet): Waterbody(&bay if applicable}: m <br /> 5.Type of permit being applied for(Check all that apply): <br /> O EROSION CON1'ROL ��)� ���: �y���},f O WATERBODY CROSSINGS/STRUCTL3RE5 <br /> ❑ FLOODPLAIN ALTERATIOIV �`�� #�.y� ,;�•,� rL ❑ STORMWATER MANAGEMENT <br /> ❑ WBTLAND PROTEC7'ION x .';,G^_ ❑ APPROPRIATIONS <br /> ❑ DREDGING ❑ 1LLICIT DISCHARGE <br /> ❑ SHORELINE/STREAMBANK STABILIZAT[ON <br /> 6.Project purpose(Check all ttial apply): <br /> � SINGLE FAMILY HOMB C] MULTI FAMILY RESIDENTIAL(apartments) <br /> O ROAD CONSTRUCTION ❑ COMMERC►AL or INSTIT'UTIONAL <br /> ❑ UTILITIGS O SUBDNISIONS(include number of lots) <br /> ❑ DEtE.DGING f� t,ANDSCAP[NG(pools,berms,etc.) <br /> ❑ SHORGLINE/STREAMBANK S'CABIL[ZATION ❑ OTHER(DESCRIBE): <br /> 7.NPDES/SDS General Stormwater Permit Number{if applicable): <br /> 8.Waterbody receiving runoff from site: <br /> 9.Project Timelinc: Start Date: 311/15 Completion Date: 9i1/15 <br /> Permits have been applied for:City �County �MN Poilution Contral Agency ❑DNR ❑COE ❑ <br /> Permits have been received: City—�County-�MN Pnllution Conirol Agency_�DNR�COE� <br /> By signing below,I hereby request a pennit to authorize the activities described herein.l ceRify that 1 am familiaz with MCWD <br /> Rules and that the proposed activity will be conducted in compliance with these Rules.1 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 btained may be subject to federal,state and/or loca) <br /> admi�tive,civil and/or criminal pen 'es. . ,, <br /> ��I�'�'�! ', �'�" J ' , : <br /> .� � ! , , . �/�J j,, �'�f <br /> Signature Each Property Ow r � Date W <br /> t„�;sc :7i';/�; s•�,: <br />