Laserfiche WebLink
WATER RESOURCE PERMIT APPLICATION FORM � <br /> Use this foim to notify/apply to the Mumehaha Creek Watershed District(MCWD)ofa proposod project or vrork which may fall within <br /> tl�eir juri�iction.Fill out this form co�letely and submit with your site plan,maps,etc.to the MCWD at <br /> 15320 Mianetonka Blvd Minnetonka,MN 55345. <br /> Kcep a copy for your records. <br /> YOU MUST OBTAIN ALL RE UIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1.Name of each property owner. �m���+� <br /> Mailin$Address: 161 Femd�e Road S. City: Wayzsta State: �N Zip: 55391 <br /> Email Address: �Y-Icm�gmail.com Phone: 612-237-6635 Fa�c: <br /> 2.Property Owner Representative Informadon(not required)(licensed contractor.anchitect,en�ineer,etc...) <br /> Business Name: �� Representative Name: Travis F�isted <br /> Business Address: 79�IMemadonal Drive,St�te 550 City: &�i�� State: MN Zip: �425 <br /> Email Addr�s: travis.fristed�is-9rp.com Phone: 952-426-0699 Fax: <br /> 3.Project Address: 1080&1090 He�itage Lane (,yty; Orono <br /> State: MN Zip: 55391 Qtr Section(s): NE Section(s): �� Township(s): 117 R��(S); 23W <br /> Lot: Block: Subdivision: pID; 1011723130007, 1011723130006 <br /> 4.Size of project pazcel(square feet or acres): 1.99 acxes <br /> Area of disturbance(square feet): N�APP�i�aQ Volume of excavation/fill(cubic yards):Not Applicable <br /> Area of existing impervious surface: Nat Appliceble qrea of proposed impervious surface: Not Applic�ile <br /> Length of shoreline affected(feet): N�A Waterbody(&bay if applicable): Not Appiicable <br /> 5.Type of permit being applied for(Check alt that apply): <br /> ❑ EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTIJRES <br /> ❑ FLOODPLAIN ALTERATION ❑ STORMWATER MANAGEMENT <br /> �(WETLAND PROTECTION D APPROPRIATiONS <br /> ❑ DREDGING ❑ ILLICIT DISCHARGE <br /> ❑ SHORELINElSTREAMBANK STABILIZATION <br /> 6.Pmject purpose(Check all that apply): <br /> ❑ SIIYGI.E FAMILY HOME ❑ MULTI FAMILY RESIDENTIAL(apardments) <br /> � ROAD CONSTRUCTION D COMMERCIAL or INSTITUTIONAL <br /> p (1TILTTIES O SUBDNISIONS(include number of lots) <br /> 17 DRIDCING O LANDSCAPING(pools,berms,etc.) <br /> O SHORELMFISTREAMBANK STABILiZATION �OTHER(DESCRIBE): Land Sunrey <br /> 7.NPDES/SDS General Stormwater Permit Number(if applicable): Not Applicable <br /> 8.Waterbody receiving tunoff from site: Isalated wetland and Tanager Lake <br /> 9. Project Timeline: Start Date: To Be Determined Campletion 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 w suthorize the acdvities described hereia.I certify that I am Pamiliar with MCWD <br /> Rules and that the proposed activity will be conducted in compliauce widi these Rules.l am familiar widi the i�armation <br /> contained in this application and,to the best of my krwwledge and belie�all infozmation is true,complete and accurate. I <br /> understand that prnceeding with work before all required authorizations are obtained may be subject to fiederal,state and/or local <br /> a ' 'strative civil or cri ' naltiea. <br /> � <br /> . , p���g_�� <br /> S gna of Each Pmperty Date <br /> Rc��iscd 7f 15;'13 Pa�c 1 of 1 <br />