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� 1 ��� � � <br /> � � ��� <br /> � <br /> WATER RESOURCE PERMIT APPLICATION—COMBINED JOINT NOTIFICATION FORM <br /> Use this form to notify/apply to the Minnehaha Creek Watershed District(MCWD),their engineering consultants,and the DNR of a <br /> proposed project or work which may fall within their jurisdiction.These agencies should advise you of their jurisdiction or permit <br /> requirements within 10 days.Fill out this form completely and mail with your site plan,maps,etc...to the MC�VD, 18202 Minnetonka <br /> Boulevard,Deephaven,MN 55391.Keep a copy for your records. <br /> YOU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1.Property Owner Name(Firs Las �!, Ip � IA� 1 t 1 u✓+'lS <br /> Mailing Address:3O,.a. C � City: f�t q, State:�� Zip:rj <br /> Email Address: ' Ma Phone: � —4 Fax: h <br /> 2. Location of ro osed ro� ttach ma with directions to site : <br /> ProjectAddress: �.p� ��J��Q� 1,�iV►'�L1�`L .� City: ) � ' � <br /> County:�C1�f1,t iV� Qtr Section(s): Sec � n(s): Township(s): Ra ge(s): <br /> Lot: �__ Block: Subdivision: PID: 3 <br /> 3. Size of site: .'3� Q,�,��� Area of disturbance: 7��Q square feet, or --- acres <br /> Volume of excavation (or fill):�� cubic yards Length of shoreline affected: feet <br /> Area of existing impervious surface: Area of proposed impervious surface: (�1 <br /> 4.Type of permit being applied for(Check all that apply): <br /> � EROSION CONTROL ❑ WETLAND ALTERATION <br /> ❑ STORMWATER MANAGEMENT ❑WATERBODY CROSSING <br /> ❑ FLOODPLAIN ALTERATION �SHORELINE/STREAMBANK IMPROVEMENTS <br /> ❑ DREDGING <br /> ❑ OTHER(DESCRIBE): <br /> 5.Project Purpose(Check all that apply): <br /> � SINGLE FAMILY HOME ❑MLTI.TI FAMILY RESmENTIAL HOUSING (apartments,etc. <br /> COMMERCIAL CONSTRUCTION �INSTITUTIONAL CONSTRUCTION(churches,schools,etc.) <br /> ❑ ROAD CONSTRUCTION �SUBDNISIONS(include number of lots) <br /> ❑ UTILITIES �LANDSCAPING(pools,berms, etc.) <br /> ❑ DREDGING ❑SHORELINE STABILIZATION(lakescaping,bioengineering) <br /> ❑ OTHER(DESCRIBE): <br /> 6.NPDES/SDS General Stormwater Permit number(if a licable): <br /> 7.Altematives (Describe any other sites or methods that could be used to avoid or minimize impacts to water <br /> bodies to achieve the project purposed.Attach additional sheet if needed.) <br /> 8.Project Timeline: Start Date: Completion Date: �j M !) <br /> 9.Applicants Re resenta ive ic se contractor,engineer,etc...) � <br /> Business Name:� i� 11�,�'$�'�� Representative Name: (9�L ,n �t �A�db�(1 <br /> Business Address:� 3� iM4 �1 6trd( c�cy:t�uchavw� State:��%' Zip: 5$3g � <br /> Email Address: Phone: Fax: <br /> 10.Names and addr sses of djoining property owners (Attach list if necessary): <br /> �I a —�at,o.��' �� <br /> Permits have been applied: City�County ❑ MN Pollution Control Agency (�" DI�R ❑ COE_� <br /> Permits have been received: Cit ❑ Count ❑ MN Pollution Control A enc ❑ DNR ❑ COE ❑ <br /> I hereby notify the recipients of this fonn of the project proposed herein and request 1 be advised of any pennits��r other <br /> determinations concerning this project that 1 must obtain. I understand that proceeding with work before all required authorizations <br /> are obtain maybe subject to Federal,State and/or local administrative,civil and/or criminal penalties. <br /> i✓ i'i_..-�--� .(o�����v <br /> Si nature of Propert Owner Date <br /> �1cr►n.HQr��4vu�� Kyltl�+�w►��Par�-�,�,�51 to�vl <br />