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<br /> WATER RESOURCE PERNIIT 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: �; .�Z 'r,;,2.
<br /> Mailing Address: _�I�I�� �-t.a,�.►3::,: • ��. City: �L�1,�tiz.-�1,, State: !Ltiti� � Zip: `� y '
<br /> Email Address: Phone: F�;
<br /> 2. Property Owner Representative Information(not required) (licensed contractor architect,engineer,etc...)
<br /> Business Name: ����„ �,:,.{ �.� ,�,,�;� Representative Name: ��;�,� •` < I� .� . r
<br /> Business Address:_1 c�Iz.� ?,�,�,=-�- ,z;a City:_ �,�,,:.:L J��-a,;.,;� State: titi;;, Z' •�Z
<br /> Email Address:.�_vv�:�.�+y.N.r�y�.r�-�:i��:.l• <<a., Phone: w� z--���� �..��3�3 Fax: �5 z-<<.;;i._z3-�-�
<br /> 3.Project Address: �c,,_; i3�+-��,-.,;�;z i tvti-- City: �„Zc�:�
<br /> State: �w�'• Zip: �53�Ki Qtr Section(s): Section(s): Township(s): Range(s):
<br /> Lot:_�Block:�_Subdivision:_ �:•a y/5',�4 �, �s,,,, •, PID: �i,,�i� z�z z�..,-�.��
<br /> 4. Size ofproject parcel (square feet or acres): 3 ..�1-{ �.��_rz.,�s
<br /> Area of disturbance(square feet): ��(,�r— Volume of excavation/fill(cubic yards): i,�3 Z
<br /> Area of existing impervious surface: �- Area of proposed impervious surface: �. i��i_
<br /> Length of shoreline affected(feet): � Waterbody(&bay if applicable): ��
<br /> 5.Type of permit being applied for(Check al1 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 /> �.SINGLE FAMILY HOME ❑ MULTI FAMILY RESIDENTIAL(apartments)
<br /> ❑ ROAD CONSTRUCTION ❑ COMMERCIAL or INSTITUTIONAL
<br /> ❑ UTILITIES ❑ SUBDIVISIONS(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 runofffrom site:
<br /> 9.Project Timeline: Start Date: ' 7 � ��t,r Completion Date:
<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 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 infonnation 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 /> ad ' 'strative,civil ar�d/or criminal penalties.
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<br /> � � � 1 � �.. �3-/�.
<br /> Si ature of Each mperty Owner Date
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<br /> M�.�Sx::� �.: � � :��1 JUN 2 "
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