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�__a__.__._.-__�__._�.____. <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 at: <br /> 15320 Minnetonka Blvd. Minnetonka,MN 55345. <br /> Keep a copy for your records. <br /> YOU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1. Name of each property owner: Justin Besikof and Meira Besikof <br /> Mailing Address: 16103 Crosby Cove City: Wayzata State: MN Zip: 55391 <br /> Email Address: lustin@madeirapartners.com Phone: 612-382-7352 Fax: <br /> 2. Property Owner Representative Infonnation (not required) (licensed contractor, architect, engineer, etc...) <br /> Business Name: SKD Architects, Inc. Representative Name: Steve Kleineman <br /> Business Address: 11140 Highway 55, Suite A City: Plymouth State: MN Zip: 55441 <br /> Email Address: kleineman@skdarchitects.com Phone: �63-591-6115 Fax: �63-591-6119 <br /> 3. Project Address: �00 Creek Ridge Pass City: Orono <br /> State: MN Zip: 55356 Qtr Section(s): Section(s): Township(s): Range(s): <br /> Lot: 5 Block: � Subdivision: Creekside in Corno pID; 03-117-23-12-0016 <br /> 4. Size of project parcel (square feet or acres): 40,358 square feet <br /> Area of disturbance (square feet): 20,239 square feet Volume of excavation/fill (cubic yards): 1,000 <br /> Area of existing impervious surface: � Area of proposed impervious surface: ��662 square feet <br /> Length of shoreline affected (feet): NA Waterbody(&bay if applicable): NA <br /> 5. Type of permit being applied for(Check all that apply): <br /> � 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 /> 0 SINGLE FAMILY HOME ❑ MULTI FAMILY RESIDENTIAL(apartments) <br /> ❑ ROAD CONSTRUCTION ❑ COMMERCIAL or INSTITUTIONAL <br /> ❑ UTILITIES ❑ SUBDNISIONS (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: Long Lake Creek <br /> 9. Project Timeline: Start Date: Approx. March 2015 Coinpletion Date: Approx. June 2015 <br /> Permits have been applied for: City ❑x County ❑MN Pollution Control Agency ❑DNR �COE 0 <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 wo�-k before all required authorizations are obtained may be subject to federal, state and/or local <br /> administrati , �ivil and/or cri ' al penalties. <br /> n �� � �� <br /> Signature o P operty Owner te <br /> i\l,ll�tll ., t,', 1...� 1 . `,l. 1 Cll 1 <br />