Laserfiche WebLink
PC Exhibit H <br /> WATER RESOURCE PERMIT APPLICATION FORM <br /> Use this form to notify/apply to the Minnehaha Creek Watershed District(MCWD)of a proposed project or work which may fall wi thin <br /> their jurisdiction.Fill out this form completeiy and submit with your site plan,maps,etc.to the MCWD at: <br /> 15320 Minnetonka Bivd.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: Hennepin County,Greg Moore <br /> Mailing Address: 300 South Sixth Street C�ty. Minneapolis State: MN Zip: 5•`�487 <br /> Ennail Address: 9�egory.moore@hennepin.us Phone: (612)596-7830 Fax: <br /> 2. Property Owner Representative Information(not required){licensed contractor, architect,engineer,etc...} <br /> Business Name: WSB&Assocfates, inc. Representative Name:Tom Voll <br /> Business Address: 701 Xenia Ave S#300 Ci�,; Minneapolis 5��: MN Z�F; 55416 <br /> Email Address: �oll@wsbeng.com Phone: (763)287-7175 F�: <br /> 3. Project Address: 3880 Shoreline Drive City: Orono <br /> Sta.te: MN Z�p; 55391 Qtr Section(s): Section(s}: Township(s}: Range(s): <br /> Lot: Block: Subdivlsloli: pZD; 1711723330151 <br /> 4. Size of project pazcel (square feet or acres}: 6•43 acres <br /> Area of disturbance(square feet): 13068 sq ft Volume of excavation/fili(cubic yards): <br /> Area of existing impervious surface: 3.14 acres Area of proposed impervious surface: � <br /> Length of shoreline affected(feet): � Waterbody(& bay if applicable): <br /> 5. Type of permit being applied for(Check ail that apply): <br /> � EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES <br /> � FLOODPLAIN ALTERATION � STORMWATER MANAGEMENT <br /> ❑ WETLAND PROTECTION O APPROPRIATIONS <br /> ❑ DREDGING 0 ILLICIT DISCHARGE <br /> ❑ SHORELINE/STREAMBANK STABILIZATION <br /> 6,Project purpose(Check all that apply): <br /> 0 SINGLE FAMILY HOME 0 M[JLTI FAMILY RESIDENTIAL(apartments} <br /> � ROAD CONSTRUCTION � COMMERCIAL or INSTITUTtONAL <br /> � UTILITIES 0 SUBDIVISIONS(include number of lots) <br /> ❑ DREDGING ❑ LANDSCAPING(pools,berms,etc.) <br /> ❑ SHORELINEJSTREAMBANK STABILIZATION ❑ OTHER(DESCRIBE): <br /> 7.NPDES/SDS General Stormwater Permit Number(if applicable): <br /> 8. Waterbody receiving runofffrom site:�ake Minnetonka <br /> 9. Project Timeline: Start Date:�Aril 2015 Completion Date: November 2015 <br /> Permits have been applied for. City 0 CounTy 0 MN Pollution Control Agency L7 DNR 0 COE C� <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 femiliar wi#h MCWD <br /> Rules and that the proposed activity will be conducted in compliance with these Rules.I am familiar with tt�e information <br /> contained in this application and,to the best of my knowledge and belief,all information is true,complete and accurate. I <br /> understand that proceeding with work before all required authorizations are obtained may be subject to federal, state and/or Iocal <br /> administrative,civil and/or criminal penalties. <br /> t1• �t •t4 <br /> Signature of Each Property Owner Date <br /> � <br /> K��i5c�1 �- I � i ; ('����� I �,l 1 <br /> D�C � 2 2014 <br /> � � 3 7 p� ���o�oRONo <br />