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�i.r,��i::,p�,�ti�J Y:,..,�:���_� <br /> ''��' � � 2017 a ���,� <br /> �� �e � <br /> CITY OF 0���^3� <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 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: Peter and Melissa Santrach <br /> Mailing Address: 222 Hennepin Ave#407 C�ty; Minneapolis State: MN Zip: 55401 <br /> Email Address: santrachp@yadasystems.com Phone: Fax: <br /> 2. Property Owner Representative Information (not required) (licensed contractor, architect, engineer,etc...) <br /> Business Name: Stonewood, LLC Representative Name: Nate Mitchell <br /> Business Address: �53 Lake St East C�ty; Wayzata State: MN Zip: 55391 <br /> Email Address: nateQstonewood.com Phone: 612-251-9713 <br /> F�: <br /> 3. Project Address: 1700 Bohn's Point Rd Cit Orono <br /> Y� <br /> State: MN Zip: 5�91 Qtr Section(s): Section(s): Township(s): Range(s): <br /> Lot: 3 Block: Subdivision: Auditor's Subdivision No. 349 pID; 16-117-23-22-003 <br /> 4. Size of project parcel (square feet or acres): 27,201 sq ft <br /> Area of disturbance (square feet): �, Optl Volume of excavation/fill (cubic yards): Zh� <br /> Area of existing impervious surface: Area of proposed impervious surface: 7401 <br /> Length of shoreline affected (feet):32U Waterbody(&bay if applicable): Lake Minnetonka, Crystal Bay <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 FAMILY 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 O OTHER(DESCRIBE): <br /> 7.NPDES/SDS General Stormwater Permit Number(if applicable): <br /> 8. Waterbody receiving runoff from site:Lake Minnetonka <br /> 9. Project Timeline: Start Date: Completion Date: <br /> Permits have been applied for: City �County �MN Pollution Control Agency �DNR �COE � <br /> Permits have been received: City—0 County—�MN Pollution Control Agency�DNR�COE—� <br /> By signing below, I hereby request a pernut to authorize the activities described herein.I certify that I am familiaz with MCWD <br /> Rules and that the proposed activity will be conducted in compliance with these Rules.I 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 proceeding with work before all required authorizations are obtained may be subject to federal,state and/or local <br /> administrative,civ' or criminal penalties. <br /> �- � �� zs. i�- <br /> S gnature of Each erty Owner Date <br /> Revised 7/15/13 Page 1 of 1 <br />