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PC ExhibR G <br /> � pC� C� C� QdL� ^ <br /> � � � � � � <br /> � ��-���u <br /> v�a�x�souxci��P�vii����.zc�xroN Fa <br /> Use this€arm to notify/epply to the Minnehaha.Creek Watershed District(MCWD)of a proposed 'eet or work wluch may fall 'thin <br /> thoir juriadiction.Fill out this form completely and snbmit with your sixe plan,maps, <br /> 15320 Miumetvnka Slvd.Mennetonka,MN 55345. <br /> Keep a copy fur your recaiids. <br /> YOi,T h�tUST OBTAIN,ALL UIRED AUTHOIt1ZATI0AIS BBFORE BEGINNING WORK. <br /> l.Name af each pxoperty ownez: �.�x�es l.e�� aa�o1 1l,ct�Sc• l,r�l�,c <br /> Mailing Address: y3 I�w�c� 41 city: _�,,;k State:� zip:� <br /> Email Address: Phone: Fax: <br /> 2. Praperty Ovyner Representtttive Infarmation(not required)(licensed contractor,architect,engineer,etc...) <br /> Business Neme: s�a�ewocra �I.i.c. Representative Name:__�id �ra�} <br /> Busi�ess Addtess: t5� �� I�.kt� S� Ciry: ti,�,,�„�,�a State:��Zip: S S��i <br /> Emaii Address: 1�rd►�Slo�„�x�,r,�.,ti Phone: 6tz.-k�i-Noci6 Fax: <br /> .7. riVJ�` l'1LLUiGaS. � AIW� f`Q� rJ.Y.j-'q{/L" w �+`J• �Jt�B <br /> State:�_ Zip: 55391 Qtr Section(s): Section(s): Township(s): Range(s): <br /> Lot: oQ� Block:��Subdivision: PID:�g..�t�-z3-zt-��� <br /> .4: Si�e of project parcel(square�t or acres): 2.3► o,c�es � r�1 r c.s- ,�•:� <br /> Area of disturbance(square feet): � ;os�ur,�,: t,,;.r-�- Volume of excavation/fill(cubzc yards): .c;� `?yac� <br /> Area of�xisting imperVit�vs�urface: d Area of proposed impervious surface: t� !:s, ��� sc;.r'•; <br /> Length of shoreline affected{feet): ,vca�� Watezbody(8t bay if applicable): �„ �,�„ <br /> 5. Type of pe�tmt being applied for(Check all that apply): <br /> L°f EROSION CONTROL ❑ WATERBODY CROS3INGSlSTRUCTURFS <br /> ❑ FLpOI3PLAIl�T ALTBRA',ITON ❑ 3TORM4VATER MANAGEMEI+IT <br /> ❑ WETI,AND PROTECTTON ❑ Al'PROPRIA'ITONS <br /> D DREDGll�IG � ILLI�IT DISCAARGE <br /> ❑ S�4RELINFJSTRF.A1t�ANK STABILIZATION <br /> 6. Praject purpose(ChEck all�hat apply): <br /> l� SINGL�F.AMILY HOME ❑ MULTT FAMII,Y�ESIDENTIAL(spartments) <br /> ❑ ROAD COI�TSTRUCTIOhT � COMIVIL�RCIAL or INSTTTUTIONAL <br /> p TJTII,TITF,S ❑ SUBDNiSIONS(inolude number of lots) <br /> C� DRBDGIN� � LANDSCAPING(pools,berms,et�.) <br /> ❑ SHORELIIVElST�;�;A.MB�AN��.STABILIZATTON � OTHER(DESCRIBE): <br /> 7.NPDES/SDS General Stormwater Permit Number(if applicable): <br /> 8. Waterbody receivin.g runofffx�m site: <br /> 9. Pmject Timeline; Start Date; t I Completian Date: �c � <br /> Permits have been a�pliod far: City �County �MN pollution Controi Agency �DNR �COE � <br /> Permits b8ve been reccived; City Cow�ty�MN Pollution Control A�ency�DNR�COE—� <br /> By signittg belaw,I hereby request a perniit to authar3ze the setivities dascribed har�it�.I certify t�at I am f�miIiar wifl�MCWD <br /> Rulrs snd that the pz+aposed activity will be�o�.duc4r.d in enmpliance with tk►�e Rules.I am fami�iar with the informalion <br /> aoninined in this sppiis�tirnn and,to the best of xny]mo�wledge an�d belief,all information is true,complebe and ac�urate. I <br /> undexstantl thsit groeesding wiih w�orlc�fi�re a�l requirecl sut�orizations are obtain�d msy be subject to fadarai,state end/or local <br /> administrffiive,civil and/or criminal penaltiea. <br /> li�.'�.�:Q�Z---�/� (f 3'�!G <br /> Signature o pertq Owner Date <br /> Revised 7/15/13 Page 1 of 1 <br />