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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 within <br /> their jurisdiction.Fill out this£arm 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 REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1. Name of each property owner: LL <br /> Mailing Address: f�/��p/dBnJ in,.� ��/?-G� City: ��;��g State� � Zip: SS <br /> Email Address: �D�a-A„�v i� 2 �� . C�.+� Phone: G,��� ,3`� O�ax: �1/e.�• <br /> 2. Property Owner Representative Information(not required) (licensed con.tt-actor, architect, engineer, etc...) <br /> Business Name: � ,�, t ised/L�E (I-!L C Representative Name: pGTt ; <br /> Business Address: /0/� Ce d��!�l., PLi9-G�• City: � d;,,✓� , State:�Zip:� <br /> Email Address:�� �rf.a,✓`,� � ��• G o sa.� Phone: 6� Z 3�S'• D332..Fax: �• � • <br /> 3. Project Address: 1a•�' W Tt.� City: �,�Q i✓� <br /> State: M.� Zip: Qtr Section(s): Section(s): Township(s): Range(s): <br /> Lot: �_Block: _�_Subdivision: t T i o�: <br /> 4. Size of project parcel (square feet or acres): �0 4/O <br /> Area of disturbance (square feet): ��p U Volume of excavation/fill (cubic yards): .S�'SC� <br /> Area of existing impervious surface: O Area of proposed impervious surface: �8�,� <br /> Length of shoreline affected(feet): --• Waterbody(&bay if applicable): --� <br /> 5.�T'pe of permit being applied for(Check a11 that apply): <br /> Q EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES <br /> ❑ FLOODPLAIlv ALTERATION ❑ STORMWATER MANAGEIV�NT <br /> ❑ WETLAND PROTECTION ❑ APPROPRIATIONS <br /> ❑ DREDGING ❑ ILLICIT DI5CHARGE <br /> ❑ SHORELINE/STREAMBANK STABILIZATION <br /> 6. Project purpose(Check all that apply): <br /> ❑ SINGLE FAMII,Y HOME �MULTI FANIILY RESIDENTIAL(apartments) <br /> ❑ ROAD CONSTRUCTION ❑ COMIv�RCIAL or INSTITUTIONAL <br /> ❑ UTILITIES ❑ SUBDIVISIONS (include number of lots) <br /> ❑ DREDGING ❑ LANDSCAPING(pools,berms, etc.) <br /> ❑ SHORELINE/STREAMBr�NK STABILIZATION ❑ OTHER(DESCRIBE): <br /> 7. NPDES/SDS General Stormwater Permit Number(if applicable): <br /> 8. Waterbody receiving runoff from site: <br /> 9. Project Timeline: Start Date: Completion Date: /d <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 e roposed activity will be conducted in compliance with these Rules.I am farni]iar with the information <br /> conta� m this ap �ca �on and,to the b t of my knowledge and belief,a11 information is true, complete and accurate. I <br /> und stand that proc � g with work b re all required authorizations are obtained may be subject to federal,state and/or local <br /> adm � pe ties. � <br /> . <br /> Signature ofEac operLy Owner Dat <br /> Revised 7/1�/13 Fage 1 af 1 <br />