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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 mail with your site plan,maps,etc...to the MCWD, 18202 Minnetonka Boulevazd,Deephaven,MN 55391.Keep a copy for your records. , YOU MUST OBTAIN ALL REQUIltED AUTHORIZATIONS BEFORE BEGINNING WORK. 1,.Property Owner Name(First,Last):Estate of John Hollander; City Orono/Court Ordered by Henn. Co. Dist. Court Mailing Address:1209 Orange Street, City;Wilmington State:�E Zip:19801 Email Address: n/a-See attached Court Order Phone:not listed F�; not listed 2.Loca�ion of proposed project(Attach map with directions to site): Project Address:200 Hollander Road City: Orono County:Hennepin Qtr Section(s): Section(s): Township(s): Range(s): Lot: 002 Block: 001 Subdivision: Holly Acres 3rd pID; 25-118-23-44-0015 3. Size of site: 2500 Area of disturbance: 2500 square feet, or 2.12 acres Volume ofexcavation(or fill): 213 cubic yards Length ofshoreline affected: ��a feet Area of existing impervious surface: n/a-0- Area of proposed impervious surface: n/a-0- 4.Type of permit being applied for(Check all that apply): � EROSION CONTROL � WETLAND ALTERATION � STORMWATER MANAGEMENT �WATERBODY CROSSING � FLOODPLAIN ALTERATION 0 SHORELINE/STREAMBANK IlVIPROVEMENTS � DREDGING � OTHER(DESCRIBE): Fill in hole from building demolition/silt fencing as necessary 5.Project Purpose(Check all that apply): � SINGLE FAMILY HOME 0 MLTLTI FAMILY RESIDENTIAL HOUSING(apartments,etc. � COMMERCIAL CONSTRUCTION �INSTITUTIONAL CONSTRUCTION(churches,schools,etc.) � ROAD CONSTRUCTION �SUBDNISIONS(include number of lots) � UTIL,ITIES �LANDSCAPING(pools,berms,etc.) 0 DREDGING �SHORELINE STABILIZATION(lakescaping,bioengineering) � � OTHER(DESCRIBE): R,�j� ��. pt,t,� o�"i ��O✓� 6.NPDES/SDS General Stormwater Permit number(if ap licable):n/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 if needed.) 8.Project Timeline: Start Date: a.s.a.p. Completion Date: 1 week from start 9.Applicants Representative(Licensed contractor,engineer,etc...) Business Name:Farr Construction Representative Name:Fred Farr Business Address:5665 45th Street SE City: Delano State:MN Z{p;55328 Email Address: fred@farrconst.com Phone: 612.701.9781 p�; 763.972.6789 10.Names and addresses of adjoining property owners(Attach list if necessary): 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 work before all required authorizations are obtained may be subject to Federal,State and/or local administrative,civil and/or criminal penalties. No d ( �er ��ci 5 ' Z ' 2-0t � Si ture ofPro ert Owner Date Page 1 of2