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� � /_... . i- <br /> , � PC Exhibit H <br /> WATER RESOURCE PERMIT APPLICATION—COMBINED JOINT NOTIFICATION FORM <br /> Use this form to notify/apply to the Minnehaha Creek Watershed District(MCWD),their engineering consultants,and the DNR of a <br /> proposed project or work which may fall within their jurisdiction.These agencies should advise you of their jurisdiction or permit <br /> requirements within•10 days.Fili out this form completely and mail with your site plan,maps,etc...to the MCWD, 18202 Minnetonka <br /> Boulevard,Deephaven,MN 5539i.Keep a copy for yourrecords. � <br /> Y.OU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1.Property Owner Name(First,Last):�THERINE M FOX TRUSTEE 3 i I( Fo X , Tr us e� <br /> Mailing Address:1095 FERNDALE ROAD W Ci�,;WAYZATA , State:MN ZiP:55391 <br /> Email Address: N�A Phone: " 'f'�r/� Fax: tJ/q <br /> 2.Location of proposed project(Attach map with directions to site): <br /> Project Address:1095 FERNDALE ROAD W Ci�,; ORONO <br /> County:HENNEPIN Qtr Section(s): Section(s): Township(s): Range(s): <br /> Lot: Block: Subdivision:see attached description pID;02-117-23-43-0023 <br /> 3. Size of site:55,410 sf Area of disturbance: 2.Q,G�� square feet, or acres <br /> _ Volume of excavation(or fill):�_cubic yards Length of shoreline affected: NONE feet. <br /> Area of existing impervious surface:9,628 sf Area ofproposed impervious surface: 9,294 sf <br /> 4.Type ofpermit being applied for(Check all that apply): <br /> 0 EROSION CONTROL ❑WETLAND ALTERATION <br /> ❑ STORMWATER MANAGEMENT ❑WATERBODY CROSSING <br /> 0 FLOODPLAIN ALTERATION �SHORELINE/STREAMBANK IMPROVEMENTS <br /> ❑ DREDGING <br /> ❑ OTHER(DESCRIBE): <br /> 5.Project Purpose(Check all that apply): <br /> 0 SINGLE FAMILY HOME ❑MULTI FAMILY RESIDENTIAL HOUSING(apartments,etc. <br /> ❑ COMMERCIAL CONSTRUCTION �INSTITUTIONAL CONSTRUCTION(churches,schools,etc.) <br /> ❑ ROAD CONSTRUCTION �SUBDNISIONS(include number of lots) <br /> ❑ UTILITIES ❑LANDSCAPING(pools,berms, etc.) <br /> ❑ DREDGING ❑SHORELINE STABILIZATION(lakescaping,bioengineering) <br /> ❑ OTHER(DESCRIBE): <br /> 6.NPDES/SDS General Stormwater Permit number(if applicable): N/A <br /> 7.Altematives(Describe any other sites or methods that could be used to avoid or minimize impacts to water <br /> bodies to achieve the project purposed.Attach additional sheet if needed.) . <br /> N/A � <br /> 8.Project Timeline: Start Date:TO BE DETERMINED Completion Date:TO BE DETERMINED <br /> 9.Applicants Representative(Licensed contractor,engineer,etc...) <br /> Business Name:BRUCE W. SCHMITT&ASSOCIATES Representative Name:BRUCE W.SCHMITT <br /> Business Address:320 MANITOBA AVE. SOUTH Ci�,;WAYZATA State:MN Z1p;55391 <br /> Email Address:bschmitt@brucewschmitt.com Phone:952-476-6222 p�; 952-476-6228 <br /> 10.Names and addresses of adjoining property owners(Attach list ifnecessary): � <br /> S����r�-{E9�FST <br /> Permits have been applied: City_�County ❑ MN Pollution Control Agency�DNR�COE�_ <br /> Permits have been received:City ❑ County ❑ MN Pollurion Control Agency ❑ DNR ❑ COE <br /> I hereby notify the recipients of this form of the project proposed herein and request I be advised of any permits or other <br /> determinations conceming this project that I must obtain. I understand that proceeding with work before all required authorizations <br /> are obtained may be subject to Federal,State and/or local administrative,civil and/or criminal penalties. <br /> _ •_�C --�D� ��1.c�� s// 5�Q C� <br /> Signature ofProperty wner Date <br /> Page 1 of2 <br />