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�.,,,� <br /> �� Y-�" - ` Print Form <br /> ��'� i �a `; <br /> �:' .. - <br /> � � � `�' � � � � �� �'�TER RESOi1RCE PERNIIT APPLICATION FOR�i <br /> Li,c this fonn tu uotii���a��1�1��to t(ie vliuuehaha Creck Watershed District (I�9C��ll)ul a pr��l���scd proiecf or work which ma}'fall within <br /> th�ir iuri�diction. Fill out this for�u c<�mplctely ancl suhmit�vith y�our site plan_niaps,ctc. to tl�c MCWI)at <br /> I�320 Miimetonl:a Blvci. Minnetonka,���>3d5. <br /> Keep a copy t<n�yoi�r recor�ls. <br /> YOU MUST OBTAII�1 ALL REQUIRED AUTHOR[ZATIONS BEFORE BEGINNING WORK. <br /> l. Naine of each properiy o���ner: Chamberlain Capital LLC <br /> Mailin`�Address: 11578 Chamberlain Ct Ci�y,: Eden Prairie State: MN Zip: 55344 <br /> Email Acldress: Paul@Chamberlaincap.com Phone: 952-649-7653 Fax: <br /> ?. Property Ow�ner Representltive Information (not required) (liceused contractor, architect, engineer, etc...) <br /> Business Name: Representati�-°e Name: <br /> Blisiness Address: Ciry: St1te: Zip: <br /> Email Address: Phone: Fax: <br /> 3. Project Address: 1340 Fox Street Ci�y. Orono <br /> State: MN Zip: Qtr Section(s}: Section(s): To��rnship(s): Ran�e(s): <br /> Lot: 13,14,15 Block 14 Subdiv°ision: PID: 02-117-23-31-0056 <br /> 4. Size of project parcel (sc�uare feet or acres): 150 x 129 <br /> Area of disuirbance(sc�uare feet): 5000 Vohmle of excavation/till (cubic yards): <br /> Area o(�existing impervious surface: 1544 Area oFproposed impervious surface: 4274 <br /> Len�th oCshoreline affected (feet): � Waterbody(& bay if applicable): <br /> 5. Type of pei-mit being applied for(Check all tllat apply): <br /> � EROSION CONTROL ❑ W�TERBODY CROSSINGS+'STRUCTURES <br /> ❑ FLOODPLAIN ALTERATI0�1 ❑ STORI�1VdATER NlANAGEMENT <br /> ❑ �G'ETLAND PROTECTION ❑ APPROPRIATIONS <br /> ❑ DREDGING ❑ ILLICIT DISCHARGE <br /> ❑ SHORELINEiSTREAMBANK STABILIZATION <br /> 6. Project purpose (Clieck all that apply): <br /> � SINGLE FAMILY HOME O NlULTI FA1��11LY RESIDEi�ITIAL (apartments) <br /> ❑ ROAD CO'�STRUCTION ❑ COMI�IERCIAL or INSTITUTIONAL <br /> ❑ UTILITIES ❑ SUBD[VIS10�lS (includc numbcr oClols) <br /> ❑ DREDGI'�IG ❑ LANDSCAPING (pools,bern�s, ctc.) <br /> ❑ SHORELINEiSTREAMBANK STABILIZATION ❑ OTHER(DESCRIBE): <br /> 7. NPDESISDS General Stormi��ater Permit Number(if app(icable): <br /> 8. Waterbody recei��ing runoff from site:Minnetonka <br /> 9. Project Timeline: St�rt Date: 5.1.15 Completioi7 Date:10.1.15 <br /> Pcrmits ha�-e becn applicd for: Ciry �Cotmty 0 'vIN Pol�ution Control Ageney �DNR 0 COE � <br /> Per�nits ha��e been receivcd: City �County 0 YIN Pollution Control Agency�DNR�COE�� <br /> 13y si��niiig helu«�•, I liereby request a pcimit t�>autliori�e tlie activities ciescrib��l herciu. 1 certify tliat [ain farniliar witl� MCWD <br /> Rules ancl that the�,rup�»eel arUvit�«�ill he conducted in compliance�vitli thcse Rules. I am famili�r�vith ll�e int��rmation <br /> coutained in tl�is application and. to th�b�st ot�mv kn�ni�ledge anel laelirf,all inti�i�mation is trtte,raulplete aii<i accurate. I <br /> und�rstancl that proceeiling with uc,rk b�ii�re a(1 rr�luired autlxnizations arc obtained may be subiect to fedeial, state aneliur lucal <br /> adlninistiative, civil and�or criminal penalties_ �� <br /> �� <br /> � ;�� �.10.15 <br /> �i��nah�re oi l�.ach Pro��crty O���ner Oatc <br /> �� APR 1 0 2015 �� <br /> By �; e w�J <br />