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Print Form <br /> WATER ItESOURCE 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 fai)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,tiS?V 55345. <br /> Keep a copy for your records. <br /> YOU �1UST OBTAiN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1. Name of each property owner: DBG, LLC <br /> Mailing Address: 4725 West Lane C�ty: Minnetrista State: MN Zip: <br /> Email Address: � � � � Yhone: 651-295-0472 Fax: <br /> 2. Property Owner Representative Information (not required) (licensed contractor, architect, engineer, etc...) <br /> Business Name: M & M Home Contractors, Inc. Representative Name: Mike Fritz <br /> Business Address: 413 Paul Ave S., PO Box 90 C�ty; Cologne State: MN Zip; 55322 <br /> Email Address: mfritr@mandmquality.com Phone: 612-554-2556 Fax: <br /> 3. Project Address: 4220 Chippewa Lane C�ty; Minnetrista <br /> State: MN Zip: Qtr Section(s): Section(s): Township(s): Range(s): <br /> Lot: 1 Block: � Subdivision: Chippewa 2nd Addtion p�p: 31-118-23-42-0012 <br /> 4. Size of project parcel (square feet or acres): 86,759 sq ft <br /> Area of disturbance (square feet): 6000 Volume of excavation/fill (cubic yards): <br /> Area of existing impervious surface: 2300 Area of proposed impervious surface: 5000 <br /> Length of shoreline affected (feet): Waterbody(&bay if applicable): <br /> 5. Type of permit being applied for(Check all that apply): <br /> � EROSION CONTROI. ❑ WATERBODY CROS5INGS/STRUCTURES <br /> ❑ FLOODPLAIN ALTERATION � S'CORMWATER MANAGEMEN"T <br /> ❑ WETLAND PROTECTION D APPROPRIATIUNS <br /> ❑ DREDGING ❑ ILLICI"T D[SCHARGE <br /> ❑ SIIORELINF,/STREAMBANK STAB(LIZATION <br /> 6. Project purpose (Check all that apply): <br /> O SINGLE FAMILY HOME ❑ MUL'I'I FAMILY RESlDENTIAL (apartments) <br /> O RUAD CONSTRUC'I'ION O COMMERCIAL or INSTITUTIONAL <br /> ❑ UTILITIES ❑ SUBDIVISIONS (include number of lots) <br /> ❑ DREDGING ❑ LANDSCAPING(pools, berms, etc.) <br /> ❑ SHORELINE/STREAMBANK STABlt.17.,ATION O OTHER(DESCRIBE): <br /> 7. NPUES/SDS General Stormwater f'ermit Number(if applicable): <br /> 8. Waterbody receiving runoff from site: <br /> 9. Project Timeline: Start Date: 3/15/16 Completion Date:1/1/16 <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. t <br /> understand that proceeding with work before aU required authori�ations are obtained may be subject to federal,state and/or local <br /> administrative,civil and/or criminal penalties. <br /> � - , . <br /> Signature of Each Property Owner Date <br /> _ .. _ !, ' . _, <br />