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\ <br /> R������� Print Form <br /> ' ` AUG � ;.� ?_016 <br /> WATER RESOURCE PERMIT APPLICATION FOR1V���r OF �,F� (� <br /> Use this form to notify/apply to the Minnehaha Creek Watershed District(MCWD)of a proposed project or work w ic �may all 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 OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1. Name of each property owner: _(� � -r � c.-1 i�„c•� �� j �t' <br /> Mailing Address:'� o;�� i��.�Y �I� '� S��.ck1� City: j�(1 �)S State: l�l;t! Zip: �'��p; <br /> Email Address: �'�c. � ^ l ^�;,,� •,- �.� c �.� Phone:l.:�a .'`Ft��, ••'�,�l C Fax: <br /> 2. Property Owner Representative Information (not required) (licensed contractor architect en ineer etc...) <br /> BusinessName:�c:��n-.�\��,v�:����.�C'iur,'. y.t�l �-- RepresentativeName: ��lii i-�����Q.r tt i <br /> Business Address:�5�3 '}�;vryc�-'i�-i �;p`' ,�1 City: '�`(� ��5 State:('��^,I Zip: 'j`_i'--1 �`` <br /> Email Address: ' �� � p���-��,����N;,�,,,,.�r�f�,i�r,�.Phone: � 13� -�3 ""+'} -�36=j- 1 Fax: <br /> 3. Project Address: �1�..� t�4iY��•, 'i.�� ;� c� �12- City: rt; ^�t� <br /> State: �1� Zip:5 r 56�1 Qtr Section(s): Section(s): Township(s): Range(s): <br /> Lot: ti+�, !� Block: Subdivision: j.�4 md; �.,�Nc��=� PID: 0�3 - ��� � J.'s-�.i - C�C��, <br /> 4. Size of project parcel (square feet or acres): I�,� 6U ; <br /> Area of disturbance (square feet): ���� , Volume of eXcavation/fill (cubic yards): '�� <br /> Area of existing impervious surface: �t� Area of proposed impervious surface: `� �;�,S S <br /> Length of shoreline affected (feet): �' O— Waterbody(& bay if applicable):�,�ke{�'�(v,� c�t�.� _. j�c: �'rr� <br /> 5. Type of permit being applied for(Check all that apply): <br /> EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES <br /> ❑ FLOODPLAIN ALTERATION ❑ STORMWATER MANAGEMENT <br /> ❑ WETLAND PROTECTION ❑ APPROPRIATIONS <br /> ❑ DREDGING ❑ ILLICIT DISCHARGE <br /> ❑ SHORELINE/STREAMBANK STABILIZATION <br /> 6. Project purpose (Check all that apply): <br /> SINGLE FAM[LY HOME ❑ MULTI FAMILY RESIDENTIAL (apartments) <br /> ❑ ROAD CONSTRUCTION ❑ COMMERCIAL or INSTITUTIONAL <br /> ❑ UTILITIES ❑ SUBDIVISIONS (include number of lots) <br /> ❑ DREDGING ❑ LANDSCAPING(pools, berms, etc.) <br /> ❑ SHORELINE/STREAMBANK STABILIZATION ❑ OTHER(DESCRIBE): <br /> 7. NPDES/SDS General Stormwater Permit Number(if applicable): <br /> 8. Waterbody receiving runoff from site: Lc� k. �(`ti i N N�'o�vk�� <br /> 9. Project Timeline: Start Date: 3 C p �� 11�� Completion Date: �7 1� �� <br /> Permits have been applied for: City �County �MN Pollution Control Agency 0 DNR 0 COE � <br /> Permits have been received: City 0 County �MN Pollution Control Agency 0 DNR �COE � <br /> r <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 the proposed activity will be conducted in compliance with these Rules. [am familiar with the information <br /> contained in this application and,to the best of my knowledge and belief,all information is true,complete and accurate. I <br /> understand that pro 'ng with work befare all required authorizations are obtained may be subject to federal, state and/or local <br /> administra� civ and%'pr cr' inal alties. <br /> Signature of Each Property Owner Date <br />