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Print Form <br /> . . �... <br /> WATER RESOURCE PERNIIT APPLICATION FORM <br /> Use this form to notify/apply to the Minnehaha Creek Watershed District(MCWD)of a proposed proj ect 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: C��a 5�,,�.•��r <br /> Mailing Address: 3esS ��.k�w�w City: a State:,� Zip: 55 33! <br /> Email Address: Phone: ��z- o- Fax: <br /> 2. Property Owner Representative Information(not required) (licensed contractor, architect, engineer,etc...) <br /> Business Name: Representative Name: <br /> Business Address: City: State: Zip: <br /> Email Address: Phone: Fax: <br /> 3. Project Address: o City:� n�rl� <br /> State:�_ Zip: 553T Qtr Section(s): Section(s): Township(s): ange(s): <br /> Lot: Block: Subdivision: PID: <br /> 4. Size of project parcel(square feet or acres): d• K3 ��r�s <br /> Area of disturbance (square feet): +�- ��o0o s, F.� Volume of excavation/fill (cubic yards): --- <br /> Area of existing impervious surface: — Area of proposed impervious surface: ' <br /> Length of shoreline affected (feet): -- Waterbody(&bay if applicable): <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 /> O DREDGING ❑ ILLICIT DISCHARGE <br /> ❑ SHORELINE/STREAMBANK STABILIZATION <br /> � 6.Project purpose (Check all that a 1 • <br /> �SINGLE FAMILY HOME �v»o �+7eh oK ❑ MiJLTI FAMILY RESIDENTIAL(apartments) <br /> ROAD CONSTRUCTION ❑ CONIIVIERCIAL or.INSTITUTIONAL <br /> ❑ UTILITIES ❑ SUBDIVISIONS(include number of lots) <br /> ❑ DREDGING ❑ LANDSCAPING(pools,berms,etc.) <br /> O SHORELINE/STREAMBANK STABILIZATION ❑ OTHER(DESCRIBE): <br /> 7.NPDES/SDS General Stormwater Permit Number(if applicable): <br /> 8. Waterbody receiving runoff from site: Ldk� ,,, <br /> 9.Project Timeline: Start Date: �' �{�,,��, Z y Completion Date: � <br /> Permits have been applied for: City �County �NIN Pollution Control Agency �DNR �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 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 a11 required authorizations are obtained may be subject to federal,state and/or local <br /> administrative,civil and/or criminal penalties. <br /> P� 9�.L ��� ��� �� �� <br /> Signature of Each Property Owner �a j�- ;� !: Date <br /> p C� � � �� �_.� �r , , � <br /> ; <br /> MAR 1 � �a;� ' : <br /> ,�.,a <br /> Revised 7/15/13 �'�age 1 of l,`�n�__4 � <br /> ..� <br />