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WATER RESOURCE PERMIT APPLICATION FORM <br /> Use this form to notifylapp(y to the Minnehaha Creek Watershe�District(MCWD)of a proposed project or work which may fall within <br /> tt�ir jurisdiction.Fill out this form completely and submit with your site plan,maps,etc.to the MCWD at: <br /> 15320 Minnetonka Blvd.Minnetonka,MN 55345. <br /> Keep a copy for your records. <br /> YOU MUST OBTAIN ALL RE UIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1.Name of each property owner: �Ymond Lipk�n <br /> Mailing Address: 161 Femdale Road S. City: Wayzata State: MN Zip: 55391 <br /> Email Address: �Y•���Smail.cam Phone: 612-237-6635 F�; <br /> 2. Property Owner Representative Information{not required)(licensed contractor,architect, engineer,etc...) <br /> Business Name: ISG Representative Name: Travis Fristed <br /> Business Addtess: 7900 Intemadonal Drive, Suite 550 City: ����� State: �N Zip: 55425 <br /> Email Address: ��s.fisted�is-grp.com Phone: 952-`�26-O6gg Fax: <br /> 3. Project Address: �080&1090 Heritage Lane City; Orono <br /> State: �N Zip: 55391 Qtr Secrion(s): NE Section(s): �0 Township(s): ��� Range{s): 23W <br /> Lot: Block: Subdivision: PID: 1011723130007, 1011723130006 <br /> 4. Size of project parcel (square feet or acres): 1.99 acres <br /> Area of disturbance(square feet): Not Applicable Volume of excavation/fill (cubic yards}: Not Applicable <br /> Area of existing impervious surface: Nat Applicable prea of proposed impervious surface: Not Applicable <br /> Length of shoreline affected(feet): N�A Waterbody(&bay if applicable): Not Applicable <br /> 5. Type of permit being applied for(Check all that apply}: <br /> ❑ EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES <br /> ❑ FLOODPLAIN ALTERATION ❑ STORMWATER MANAGEMENT <br /> �( WETLAND PROTECTION D APPROPRIATIONS <br /> ❑ DREDGING ❑ ILLICIT DISCHARGE <br /> ❑ SHORELINE/STREAMBANK STABILIZATION <br /> 6. Project purpose(Check all that apply): <br /> ❑ SINGLE FAMILY HOME ❑ MULTI FAMiLY RESIDENTIAL(apartments) <br /> ❑ ROAD CONSTRUCTION O COMMERCIAL or INSTITUTIONAL <br /> � UTILITIES ❑ SUBDNISIONS(include number of lots) <br /> D DREDGING ❑ LANDSCAPIIVG(pools,berms,etc.) <br /> ❑ SHORELINFJSTREAMBANK STABILIZATION � OTHER(DESCRIBE): Land Survey <br /> 7.NPDES/SDS General Stormwater Permit Number(if applicable): Not Applicable <br /> 8. Waterbody receiving runoff from site: Isdated wetland and Tanager Lake <br /> 9. Project Timeline: Start Date: To Be Determined Completion Date: <br /> Permits have been applied for: City County MN Pollution Control Agency DNR COE <br /> Permits have been received: City County MN Pollution Control Agency DNR COE <br /> By signing below,I hereby request a permit to authorize the activities described herein.I certify that I am familiar with MCWD <br /> Rules and that the proposed activity will be conducted in compliance with these Rules. I am familiar with the information <br /> contained in this application and,to the best of my knowledge and belief,all infnrmation is we,complete and accurate. I <br /> understand that proceeding with work before atl required authorizations are obtained may be subject to federal,state and/or local <br /> a ' istrarive civil or cri ' nalties. <br /> � <br /> � ' as^��g-�,� <br /> S gna of Each Property wn Date <br /> Rc��i�cd 7,15;'13 Pa�,c 1 of 1 <br />