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,.-._:.. <br /> -- _. .....----- <br /> 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 form completely and submit with your site p1an,maps,etc.to the MCWD at: <br /> 15320 Minnetonka Blvd.Minnetonka,MN 55345. <br /> Keep a copy for your records. <br /> YOU MUST OBTAII�1 ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> l. Name of each property owner: GL <br /> Mailing Address: J���GQ/d6rJ ir�,.�,�/�—City: ��;�rq State� � Zip: SS <br /> Email Address: �D��w„�v i`�Q �F�.L'p.�.� Phone: �� ,S� 4��: iUe.�• <br /> 2. Property Owner Representative Information(not required) (Iicensed contractor, architect, engineer, etc...) <br /> Business Name: �,7-g,,, t z�d/L �E �/-!L C Representative Name: p�Ttrz. �� �J:S <br /> Business Address: /Q/� �p v t•�l�� PL�C�c • City: ��;,,✓� , 5tate:�Zip:� <br /> Email Address:�� �ri.z,v`,c� � ,,h�. G o� Phone: 6/2 3�S• 0332-Fax: �• ""� ' <br /> 3. Project Address: rL.� r�T�. � �J L , City: 0�2d�✓� <br /> State: M.� Zip: Qtr Section(s): Section(s): Township(s): Range(s): <br /> Lot: Z. Block: _�_Subdivision: t T ��o�: <br /> 4. Size of project parcel (square feet or acres): �30 Sr� <br /> Area of disturbance (square feet): �da U Valume of excavation/fill (cubic yards): �S"S`G <br /> Area of existing impervious surface: Q Area of proposed impervious surface: ���,� <br /> Length of shoreline affected(feet): ---• Waterbody(&bay if applicable): --� <br /> 5.�T'pe of permit being applied for(Check all that apply): <br /> C+� EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTiJRES <br /> ❑ FLOODPLAIN ALTERATION ❑ STORMWATER MANAGEMENT <br /> ❑ WETLAND PROTECTION ❑ APPROPRIATIONS <br /> ❑ DREDGING ❑ ILLICIT DISCIIARGE <br /> ❑ SHORELINE/STREAMBANK STABILIZATION <br /> 6. Project purpose(Check all that apply): <br /> ❑ SINGLE FAMII�Y HOME �MIJLTI FAMILY RESIDENTIAL(apartments) <br /> ❑ ROAD CONSTRUCTION ❑ COMIv�RCIAL ar INSTITUTIONAL <br /> ❑ UTILITIES ❑ SUBDNISIONS (include number of lots) <br /> ❑ DREDGING ❑ LANDSCAPTNG(pools,berms, etc.) <br /> ❑ SHORELINE/STREAMBANK STABILIZATION ❑ �THER(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: <br /> Permits have been applied for: City County �MN Pollution Control Agency DNR 0 COE 0 <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 herei.n. 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 familiar with the information <br /> cont � in this ap �ca �on and,to the b t of my lmowledge 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 � im� pe ties. , <br /> . � � <br /> Signature ofEac operty Owner Date <br /> Revised 7/1�/13 Page 1 of 1 <br />