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: <br /> WAT�R RI;SOURC�P�R'�TIT APPLICATION—COMB1Ni;D.70INT�tOTIFICA�'ION I'OR11�I <br /> Use this fonn;o notify/apply to the A4iunehaha Creek\Vatershed District(MC1VD),ti�eir enguieering consultAnts,aua the D\TR of a <br /> proposed project or work tivhich may fall with[n thair jurisdietion.These egencies siioutd 2dvisa you ofil�eir jurisdiction orpermit <br /> requirements tivithui 10 day�.Fi(!out this form con�plctcly uid n�ail�vitli your sita plan,maps,etc.,.to tlie�4C1'JD,!3202�Qim;etonkn <br /> Haulevard,Deephaven,NIN 55391.Keep a copy for}�our rccords. <br /> YOU MUST OBTAIN AT,L REQiJIRED AI3THORTZATIO1�tS BF.FORE BEGL'�NIIti�G tVORK, <br /> 1.Pi•operty O�vtierNante(First,Last): f�l� W /1'�,¢.SCYi W� <br /> Mailing Address: �y�5' ��ev (�oad _City;�o,� L� State:�_ Zip: ejS3� <br /> Email Address:ma m L'Gal �w o . Phoi�e: Fax: <br /> 2.Location ofproposed project(Atta i map vrtli d'rections to site): <br /> ProjectAddress: 32ro Gvah�w• 1-��I� le� City:_ O✓'ono <br /> County:_ eHn Qh�Seciion(s): Section(sa: To�vnship(s); Ra�i�e(s): <br /> I31ock• Z SUVd1VISl0I1: rahav►�1-1-1�H^�vw2 PID: os- l� 7-Z3-ll- <br /> Lot: i , Q� <br /> _. _ _------_ _.__ _ <br /> 3.Size ofsite: /�F6,76 Ai•ea of disturba�ice: square feet,or acres <br /> Volume ofexcavation(or fill}: 7�FZ cuUic yards Le�igtl�ofshoreline af�ected: N/�4 feet <br /> A�ea of existing impervious surface: N f�- __ Area ofpi•oposed impervious surface: 9Z/o <br /> 4.Typa of permit being applied for(Check all tt�at apply): <br /> � EROSION CONTROL 0�VJs"PLAND ALTERA'TION <br /> E� STORMI'VATER MAAtAGEMENT ��VATEItBOAY CROSSIIYU <br /> �-J FLOODPLAIN ALTERATION �SHORELINE/STREAMBANK II��ROVEMLNTS � <br /> � DRBDGING <br /> � OTI-IER DBSCI�IBE}: <br /> 5.Project Purposa(Check all that a 1 ! <br /> Pp Y)� <br /> � STNGLE FAVIII,Y HOME j�MULTI FAMILY RESIDENTFAL HOUSING(apa�tments,eta} � <br /> - COMMERCIAI,CONSTRUCTION �INSTITUTIONAL CONSTRUCTION(cliurclles,scltools,ete.) � <br /> � ROAD CONSTRUCI'ION []SUBDNISIONS(include number of lots) ' <br /> � t3TiLITIES �LANDSCAPI�vG(poots,bernis,etc,) ! <br /> � DREDGII�TG 0 SHOREL�'E STABILIZATION(lakescaping,bioe�3giiteering) i <br /> �] OTHER ESCRIDE : <br /> 6.NPD$S/SDS Ge�tei�al Storni�vater Pei•mit�ium6er(if a licable): N/�l __ _ � <br /> 7.Altematives(Describe any other sites or methods diat could ba used to avoid or minimize impacts to tvater <br /> bodies to achieve t}te project puiposed.Attach additional sheet ifne2ded.) ; <br /> N A i <br /> _- --- , <br /> 8.Project'Timclnic: Sfart Datc: �'Vl a 20�3 Completion Date;_ aec, zor3 <br /> 9.Applicants Representativo(7,'censed conti�acior,engineer,etc.,.) / f J <br /> BusiitessName: Ch� .�5_,__� I�ovo �.Represeirtativel`Ta�ne: ��wt L� L[SVe � <br /> Business Address: �So 5� 2,3 ALe. itl City:__ f�( rno,Jf'�• SEate: MI�(Zip; Sr,�{y 7 ' <br /> Email Addi�ss: '�rn r C� c hart¢s c�dd•ccw, Phoiie: �012� S4-t�39 Fax; ��2-loo�f-�2 39 � <br /> - -- — ._. <br /> 10.Names and a resses of'adj qining properiy owners(Attaclt list ifnecessary): '; <br /> ciec �4�(ac ha� ��- � <br /> Pennits have been applied:Ci[y__�_County 0 MN Pollution Controt Agency�_Di�IR_„�(" CQB� <br /> Permits I�ave been received:City Cl County � MN Pollution Cont�nl Agenc � DNR I� COB �J <br /> I hereby notify the recipienls of this form ofthe project proposed hecein and request I be advised ofany permits or otlier <br /> determ'viations concerning i�. roject that I niust obtain,I understand thatproceeding with work before all requireti authorizalions <br /> are obt�i d may be��bjeJ to�ederai,State ancVor tocal adnwiistrati��e,civil and/or criminal penalCes. <br /> _ � �,� J ti <br /> x a `� 1 <br /> Si i ture fPropert Owner Date <br /> � <br /> Page 1 of2 <br />