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,.-t-. <br /> ---... _...----- <br /> WATER RESOURCE PERMIT APPLICATION FORM <br /> Use this fortn to notify/apply to tlae Minnehaha Creek Watershed District(MCWD)of a proposed project or work which may fall within <br /> their jurisdiction. Fill out this form 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 OBTATN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1. Name of each property owner: ��',��� BiLveJ� �i� GL C _ ^ <br /> Mailing Address: f�/�GQ/dB�J ir�;� �'.�/9-G� City: ��;��g State/f�it/ Zip: S� <br /> Email Address: �D��A,�v�4 e ,�jF . C�t•� Phone: ff/� •►�,s� 0��� ille.�• <br /> 2. Property Owner Representative Information (not required) (Iicensed contractor, architect, engineer, etc...) <br /> Business Name: S Te��.r G �Rr9dIL �(/-!L C Representative Name: ; <br /> Business Address: �4 Ce d c•���; pG/9�C�c • City: ��d;,,✓A , State:�Zip;� <br /> Email Address:�� s"r�.a,d`�E ,�L� • G o� Phone: (,� 2 3�,5'• d332Fax: N� � + <br /> 3. Project Address: b N..+' c�J ll C K ri i J C , City: ��d�✓� <br /> State: /N.�v Zip: Qtr Section(s): Section(s): Township(s): Range(s): <br /> Lot: _�_Block: �_Subdivision: t T ri o�: <br /> 4. Size of project parcel (square feet or acres): �0 Y o <br /> Area of disturbance (square feet): �dp p Volume of excavation/fill (cubic yards): .SMs`C> <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 e of pezmit being applied for(Check a11 that apply): <br /> Q EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCT'URES <br /> ❑ FLOODPLAIN ALTERA.TION ❑ STORMWATER MANAGEMENT <br /> ❑ WETLAND PROTECTION ❑ APPROPRIATIONS <br /> ❑ DREDGING ❑ ILLICIT DISCHARGE <br /> ❑ SHORELINE/STREAMBANK STABILIZATION <br /> 6. Project purpose(Check all that apply): <br /> ❑ SINGLE FAMII,Y HOME �MULTI F�M�,Y RESIDENTIAL(apartments) <br /> ❑ ROAD CONSTRUCTION ❑ COMIV�RCIAL or INSTITUTIONAL <br /> ❑ UTILITIES ❑ SUBDIVISIONS (include number of lots) <br /> ❑ DREDGING ❑ LANDSCAPTNG(pools,berms, etc.) <br /> ❑ SHORELINE/STREf1MBANK 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: 0 I <br /> Permits have been applied for: City County -0' MN Pollution Control Agency �DNR 0 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 certi�y that I am familiar with MCWD <br /> Rules and that e roposed activity will be conducted in compliance with these Rules. I am familiar with the information <br /> cont � m this ap �ca �on and,to the b t of my knowledge and belief,all 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 andlor local <br /> adm � im� pe ties. , <br /> . <br /> Signature ofEac operty Owner Date <br /> Revised 7/1�/13 Page 1 of i <br />