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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 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: Lr`� � <br /> Mailing Address: ��(�j,�j �„bl�(r��� (�('�, '' '1►�21� City: State: � �ip: 553fi�o <br /> Email Address: Phone: Fax: <br /> 2. Property Owner Representative Information(not required) licensed contractor, architect, engineer, etc...) <br /> �usiness Name: j�Q��ll[���__�,1�ck.�r IN1.�N������ �S <br /> Business Address: Q p,Q���t City: �Q(l,j J�L�a QR IZ 4� State: �l Zip: �_ <br /> Email Address: o � , Phone: gs'�1 y71 -O?SS Fax: <br /> 3. Project Address: City: L�fJ G <br /> State: W11� Zip: $�3SIo Qtr Section(s): Section(s): Township(s): Range(s): <br /> Lot: Block: Subdivision: P�� <br /> 4. Size of project parcel (square feet or acres): <br /> Area of disturbance(square feet): � ��$ Volume of excavation/fill (cubic yards): , <br /> Area of existin impervious surface: Area of proposed impervious surface: <br /> Length of shoreline affected (feet): I,Z4 Waterbody(&bay if applicable): (,O�t 6 l.Mlck� <br /> 5. Type of permit being applied for(Check all that apply): <br /> ❑ EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES <br /> I�Q FLOODPLAIN ALTERATION ❑ STORMWATER MANAGEMENT <br /> ❑ WETLAND PROTECTION ❑ APPROPRIATIONS <br /> ❑ DREDGING ❑ ILLICIT DISCI-IARGE <br /> ❑ SHORELINE/STREAMBANK STABILIZATION <br /> 6. Project purpose(Check all that apply): <br /> ❑ SINGLE FAMILY HOME ❑ MULTI FAMII,Y RESIDENTIAL(apartments) <br /> ❑ ROAD CONSTRUCTION ❑ COMMERCIAL or INSTITUTIONAL <br /> ❑ UTII,ITIES ❑ 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: iv <br /> 9. Project Timeline: Start Date: Completion Date: <br /> Permits have been applied for• Ci �County ❑MN Pollution Control Agency �DNR �COE � <br /> Permits have been received: i �County �MN Pollution Control Agency �DNR �COE � <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. 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,civil and/or criminal penalties. <br /> Signature of Each Property Owner Date <br /> Revisecj 7!15/1� Pa�e I of 1 <br />