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� ' 1 � � <br /> WATER RESOURCE PERMIT APPLICATION FORM <br /> Jse 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 pro ert owner: Richard C. Sundberg <br /> Mailing Address: 5g2`'y West . Cit Greenwood <br /> Y� State: � Zip: 5 5 3 31 <br /> EmailAddress: sundberg.rick@gmail .com phone: (612) 298-1173 Fax: <br /> 2. Property Owner Representative Information (not required) (licensed contractor, architect, engineer, etc...) <br /> Business Name: ��,� fax omDan;P�, rn�_Representative Name: Wayne Sooj ian <br /> Business Address: 206 Minnetonka Ave S City: Wayzata State: MN Zip: 55391 <br /> EmailAddress: W����ianc�c�olfax�� �om Phone: (952) 746-4380 Fax: (952) 746-438 <br /> 3. Project Address: 1161 Elmwood Avenue City: rono <br /> State: MN Zip: 55364 Qn Section(s): Section(s): Township(s): Range(s): <br /> Lot: 918 BlOck: Subdivision: Skarp&Lindquist ' s p�:0711723140029 <br /> 4. Size of project parcel (square feet or acres): 16, 513 sf <br /> Area of disturbance(square feet): 2 6 0 5 Volume of excavation/fill (cubic yards): 3 0 0 CY <br /> Area of existing impervious surface: -�- Area of proposed impervious surface: 3 2 0 5 s <br /> Length of shoreline affected (feet): -�- Waterbody(&bay if applicable): <br /> 5. Type of permit being applied for(Check all that apply): <br /> [�EROSION CONTROL ❑ WATERBODY CROSSINGS/SZ'RUCTURES <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 /> � 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: Lake Minnetonka <br /> 9. Project Timeline: Start Date: 12 2 6 2 013 Completion Date:_0 5/3 0/2 014 <br /> Permits have been applied for: City X County MN Pollution Control Agency DNR COE <br /> Perrnits have been received: City County MN Pollution Control Agency__DNR COE <br /> By signing below, I hereby request a permit to authorize the activiries 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 work before all required authorizations are obtained may be subject to federal,state and/or local <br /> administrative,civil and/o criminal nalti . <br /> �i <br /> �igna e of Each rope Owner — � ` � L� w r � <br /> Date <br /> a,.. <br /> iSt�a i t: .4: t , x, ia�i'`(:; i t3� i <br /> I <br />