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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: Tashitaa Tufaa <br /> Mailing Address: 10980 Mississippi Dr N Clty; Champlain State: MN Zlp; 55316 <br /> Email Address: ttufaaQmetrotn.com Phone: �63-443-7592 p�; <br /> 2. Property Owner Representative Information(not required) (licensed contractor, architect, engineer, etc...) <br /> Business Name: Stonewood, LLC Representative Name: Sven Gustafson <br /> Business Address: �53 East Lake St Clty; Wayzata State: MN Zlp; 55391 <br /> Email Address: sven@stonewood.com Phone: 612-462-4000 F�: 1 sZ- �q� •�q <br /> 3. Project Address: 1830 Shoreline Drive Clty; Orono <br /> State: MN Zip; 55391 Qtr Section(s): Section(s): Township(s): Range(s): <br /> Lot: 1 and 1A Block: Subdivision: 356 pID; 10-117-.23-42-0002 <br /> 4. Size of project parcel (square feet or acres): 72300 sq ft <br /> Area of disturbance(square feet): 6000 Volume of excavation/fill (cubic yards):2038 <br /> Area of existing impervious surface: p Area of proposed impervious surface: �0000 sq ft/13.9% <br /> Length of shoreline affected(feet): Q Waterbody(&bay if applicable): Lake Minnetonka, Smith Bay <br /> 5. Type of permit being applied for(Check all that apply): <br /> 0 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 /> 0 SINGLE FAMILY HOME ❑ MLTLTI FAMILY RESIDENTIAL(apartments) <br /> ❑ ROAD CONSTRUCTION ❑ COMMERCIAL or INSTITUTIONAL <br /> ❑ UTILITIES ❑ SUBDNISIONS(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 runofffrom site:Lake Minnetonka <br /> 9. Project Timeline: Start Date: Completion Date: <br /> Permits have been applied for: City �County �MN Pollution Control Agency DNR 0 COE � <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 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 familiaz with the information <br /> contained in this application and,to the best of my knowledge and belief,all information is true,complete and accwate. I <br /> understand that proceeding with work before uired authorizations are obtained may be subject to federal,state and/or local <br /> admin' ' ,civil and/or ' pe es. <br /> � q,��,. �� <br /> Signa ure o Each Property O ner Date <br /> Revised 7/15/l3 Page l of 1 <br />