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RECEIVED , �� , . • OrT 2 3 2015 ,�.� CITY OF ORO^�O WATER RESOURCE pERMIT APPLICATYON FORM Use this form to notify/apply to the Minnehaha Creek Watershed District(MCWD)of a propoaed project or work wluch may fall within their jurisdiction.Fill out this form completely and submit with your site plan,maps,etc,to the MC,`Wll at; 15320 Miruzetonka Blvd.Minnetoaka,MN 55345. Keep a copy for your records. YQU MUST OBTAiN ALL RLs(�UIItED AUTHORIZATIONS BE�ORE BEGINNINC�WORK 1.Name of each��roperty owner:��-1 --��1�_ -- — - Ma.iling A�idress:��(� _ ,�a2�City:�,�(,�+�__.,State:� �ip: 55r��. Email Address:�/ F- / C? �I.�aTq Phone: G l a� 3T/-3�Faac:� /,�-�� 3aa7 2, Property Owner Re� esentative In�ormation(not re:quired) licensed contractor, architect,engineer, etc...) Business Name:�OC�l.l.6��.��t�C�.�_I'��t��s Business Address:Q��(�.,____ _�_�__City:,�P[�j�t(9 Q�g,{R_. State;�_Zip:�_ EmaffAddress: _�o_ C ��2!lll5�_►�r�S •_t'�Q� . Phone: �15.1 y?� ,0��' Fax:__ ____— —_ _ ' 1 3. Projcct Acicirc,s: �_ ,�OI�_�t_�� City: I.0lJ_j. ----_.____. _ �t�tc: w��1 _ 7.ip: �'g ti Qtr Section(s): Section(s}: Township(s): Range(s): � Lot: Block: SuUdivision: _ -- - --- -- -PID: __ .�--- —__. �4. Size ui'prr�ject parcel (squar� tcct or ac�•es): � E1rea�f clislurbince(scat�cir�:fect):_r�_D_4_� _— _Volume ot'exc�ivatioi�/fill (cubic y�rdy);_�,� Area ot cxistuig��mpetvious surlace: Area of pro��osed impeiviouti snrface: --- _ — _� I l.eti�,tl� of shoreline af�ccted (feet): �l� __ _ W�►terhody(& h�iy if applicahie}: _LoN b_ �.jl�}S,g___ I 5.'I�pe of perrnit being applied for(Check all that apply}; � ❑ EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURBS I I�J FLOODPLAIN ALTBRATION ❑ STORMWATBR MANAGEMENT i ❑ WETLAND PROTEGTTON O APPROPRIATTONS i � DREDGING ❑ ILLICIT DISCHARGE ❑ SHOREL7NE/STREAMBANK STABILIZATTON 6.Project purpose(Check all that apply); , ❑ SINGLE FAMILY HOME ❑ MULTI FAMlLY RESIDENTIAL(apartments) , ❑ ROAD CONSTRUCTION ❑ COMNIERCIAL or INSTITLTTIONAL � ��,�5 ❑ SUBDIVIS10N5(include number of lots) ❑ DREDGING I�I LANDSCAPING(pools,berms,etc.) ❑ SHORELINE/STREAMBANK STABIL.IZATION C7 OTHER(DESCRIBE): 7.NPDES/SDS General Stormwater Pez�nit Number(if applicabl�): _______ _ � � 8, Waterb�dy receiving runoff from site: �_�Y}�� _.__ _ _ ____—_. i 9. 1'r��jcct Tisneline; Start Date: __('c�inpletic�n Date: ' ----- - --_ —- - Permits have been applicd[i�r' ('it �County �MN Poliution Control Agency �DNR 0 COE �J i Permits have been received: 1 y _County.__-�MN Pollution Control A�,ency��I DNR^�C�E—�I �; - � By signing below,I hcreby request a permit to authorize the acdvities described herein.i certify that I am familiar with MCWD � Rules and that the proposed aciivity will ba conducted in compliance with these Rules.I am familiar with the information � contained in this application and,to the best o£my knowledge and belief,a1l information is true,completa and accurate. I understand that prc� eediu�;with work before all required authorizations are obtained may be subject to federal,state and/or local aclministr ve vil ancUc�� min�l penaltiea. i _ _., __ ---_.___ ___ _�. .��P� '�k;n� �rc aCEaCh Prnpe ,y Owner Datc Revised 7/15/13 Page { of l