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. , ` �ECEIVED �--�-- _ ._------ �E�i 2 3 2016 WATER RESOURCE PERMIT APPLICATION FO�� Use this form to notify/apply to the Minnehaha Creek Watershed District(MCWD)of a proposed o e t ay fall within their jurisdiction. Fill out this forrn 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: � Mailing Address: ��-jr i fN� �1�-Gp vi= A Ciry: � �i�1 State: � Zip: ��l� Email Address: ��SA�s.u�� a , 1'M1 f� Co w�w.. Phone: . • ax: 2. Property Owner Representative Information(not required) (licensed contractor, architect, engineer, etc...) Business Name: 'r'p� � Representa ive Name:P�'�'�,�,3 N v�.V�S BusinessAddress: �j � ��N� � �.�: ��r� ~'� Ci YY��C� �j " ty: �� State: 1'M`�.► Zip:�� Email Address: �t T�►�,v; S � �f, � C� ,,,,��, Phone: - � -� FaY: 3. Project Address: ` � City: d 1� p �J Q State: _�J_ Zip: Qtr Section(s): Section(s): Township(s): Range(s): Lot: '� '� Block: �Subdivision:�STa N E BA �? l.� ��f�ow.PID: 4. Size of project parcel (square feet ar acres): Area of disturbance (square feet): �p �� Volume of excavation/fill (cubic yards): ;,��('� Area of existing impervious surface: � Area of proposed impervious surface: � 8'�� , Length of shoreline affected (feet): --� Waterbody(& bay if applicable): '�'� 5. T e of permit being applied for(Check all that apply): EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUC'1`IJRES ❑ FLOODPLAIN ALTERATION ❑ STORMWATER MANAGEMENT ❑ WETLrLND PROTECTION ❑ APPROPRIATIONS ❑ DREDGING ❑ ILLICIT DISCHARGE ❑ SHORELINE/STREA.MBANK STABILIZATION 6. Project purpose (Check all that apply): ❑ SINGLE F�M�,Y HOME ❑ MULTI FAMII�Y RESIDENTIAL(apartments) ❑ ROAD CONSTRUCTION ❑ COMMERCIAL or INSTITUTIONAL ❑ UTII_,ITIES ❑ SUBDNISIONS (include number of lots) ❑ DREDGING ❑ LANDSCAPING(pools,berms, etc.) ❑ SHORELINE/STREA.MBANK STABILIZATION ❑ OTHER(DESCRIBE): 7. NPDES/SDS General Stormwater Permit Number(if applicable): 8. Waterbody receiving runoff from site: 9. Project Timeline: Start Date: Completion Date: Permits have been applied for: City - County �MN Pollution Control Agency 0 DNR 0 COE � Permits have been received: City -' County—0 MN Pollution Control Agency—�DNR—�COE� By signing below,I hereby request a permit 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 under t at proceeding with wor fore all required authorizations are obtained may be subject to federal,state and/or local a inis�a civ' /or iminal nalties. � ``� t� � .� � '��_ Signa e of Each Property Owner Dat�" �,, --__� Revised 7/15/13 Pa�e: 1 of 1