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l WATER RESOURCE PERMIT APPLICATION-COMBINED JOINT NOTIFICATION FORM Use this form to notify/apply to the Minnehaha Creek Watershed District(MCWD),their engineering consultants,and the DNR of a proposed project or work which may fall within their jurisdiction.These agencies should advise you of their jurisdiction or permit requirements within 10 days.Fill out this form completely and maii with your site plan,maps,etc...to the MCWD, 18202 Minnetonka Boulevard,Deephaven,MN 55391.Keep a copy for your records. YOU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. 1.Property Owner Name(First,Last): Y1't��rk l verun j� Mailing Address: 2ZS �� .5�. 5_ �Z�oc� City:'71'I�nr�.�pc:l�� State: /'`�,l� Zip: SS�c�'L Email Address: '��'►a�' -he�.�v;� ;@n - ��r� Phone:�.-��?-�[.cc F�: 2.Location of proposed project(Attach p wit d' ections to site): ProjectAddress: 33►� (;�ahavr ��;�� City: �r4;�� County: �H�:�r��o;'� Qtr Section(s): Section(s): Township(s): Range(s): Lot: G� Block: � Subdivision: t=�•�►�� z�-YVP PID: 3. Size of site: l 3 3.� 3� F . Area of disturbance: — square feet,or -7� acres Volume of excavation(or fill): cubic yards Length of shoreline affected: �%%A feet Area of existing impervious surface: � Area of proposed impervious surface: 4. Type of permit being applied for(Check all that apply): � EROSION CONTROL �WETLAND ALTERATION � STORNIWATER MANAGEMENT �WATERBODY CROSSING � FLOODPLAIN ALTERATION �SHORELINE/STREAMBANK IlVIPROVEMENTS ❑ DREDGING � OTHER(DESCRIBE): 5.Project Purpose(Check all that apply): � SINGLE FAMILY HOME ❑MULTI FAMII,Y RESIDENTIAL HOUSING(apartments,etc.) � COMMERCIAL CONSTRUCTION �INSTITUTIONAL CONSTRUCTION(churches,schools,etc.) � ROAD CONSTRUCTION �SUBDNISIONS(include number of lots) 0 UTII,ITIES OLANDSCAPING(pools,berms,etc.) ❑ DREDGING �SHORELINE STABILIZATION(lakescaping,bioengineering) � OTHER(DESCRIBE): 6.NPDES/SDS General Stormwater Permit number(if applicable): /�//A 7.Alternatives(Describe any other sites or methods that could be used to avoid or minimize impacts to water bodies to achieve the project purposed.Attach additional sheet ifneeded.) 8.Project Timeline: Start Date: J✓I � Z�;Z�'ii Completion Date: A ;•�1,�olL 9.Applicants Representative/J(Licensed contractor,engineer, etc...) Business Name: Lh.�rGc7 (�LY��) �-l�Ic,�v� Representative Name: :Ir��, �: ��,z BusinessAddress: i5� �� 3"`'A� �- Cit f( �nc✓T� State: MN Zi Y� ti, P� 5'��7 Email Address: `,ir, I C'cliarG-s�,.�►J ��:.r. Phone: ��Z'u��--`I-h y5� Fax: G�L-�:��-1 z3`i 10.Names and ad resses o adjoining property owners(Attach list if nec/.e�ssa L��'� 1'/.d�l Lv_lil: -�"dr�2r�� IL.I ? � I��T�^II.�r1� 3377 Gc,ha�r �+�1� f� 32�'�� Liahzr,r. 1-�',�� c). 34i5 , �� L��.�. Permits have been applied: City � County � MN Pollution Control Agency � DNR � COE� Permits have been received:City � County � MN Pollution Control Agency � DNR � COE � I hereby notify the recipients of this form of the project proposed herein and request I be advised of any permits or other determinations concerning this project that I must obtain.I understand that proceeding with wark before all required authorizations are obtai d may be subject to Federal,State and/or local administrative,civil and/or criminal penalties. 7��qlt� Sig ature ofProper� wner Date—' T Page 1 of2