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t . . � � � �5 � d � <br /> - •" WATER RESOURCE PERMIT APPLICATION FO JUN �.4 �015 <br /> Use t s r �Q,�Qtify/apply to the Minnehaha Creek Watershed District(MCWD)of a proposed pr or work whic may f ithin <br /> r,�� ��LB�I�i�jurisdiction.Fill out this form completely and submit with your site plan,maps,e .to the MCWD at: <br /> 15320 Minnetonka Blvd. Minnetonka,MN 55345. By <br /> ,�;?�� �� ORON: Keep a copy for your records. <br /> YOU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1. Name of each property owner: S o�2�c �� e t����-H-L <br /> MailingAddress: %�32i5_ �/S ll-1 A��r= � � D City: t`�� �,( � State: h(r�( Zip: 554�b <br /> Email Address: �S�c-t,�i �: So��e�z�n• e�,� Phone: - S/-0/ oo Fax: 763-55/-�l�'99 <br /> 2. Property Owner Representative Information(not required){licensed contractor, architect, engineer,etc...} <br /> Business Name: t�1G�TGc�I H-�atit� Representa.tive Name: C�{�15 �aR-�oJ <br /> Business Address: /�21 S 4 S?� �4V E N x�_� City: �L���o��-1 Sta.te: �Zip: 5���(o <br /> EmailAddress: C1-4215�! ��nln2`r7�N�M�S.�f:M Phone: �b�-��;9-Zq�/ F�:�2 -S� S/-y(9� <br /> 3. ProjectAddress: ��X �,�0;�1�+ /k¢.� o('�- City: c�Roo�iO <br /> State: � Zip: Qtr Section(s): Section(s): Township(s): Range(s): <br /> Lot: Z.Z Block: 3 Subdivision: �I��L��/t Ctn( a F o�.vn�o PID: <br /> 4. Size of project parcel(square feet or acres): z. ( /��,. <br /> Area of disturbance(square feet): �7..�_ Volume of exca.vation/fill(cubic yards): �/�-�- � <br /> Area of existing impervious surface: � Area of proposed impervious surface: �?�t-{�c'� <br /> Length of shoreline afFected (feet): �_Waterbody(&bay if applicable): N:�y <br /> 5. Type of permit being applied for(Check all that apply): <br /> � EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES <br /> ❑ FLOODPLAIN ALTER.ATION ❑ STORMWATER MANAGEMENT <br /> �f WETLAND PROTECTION ❑ APPROPRIATIONS <br /> ❑ DREDGING ❑ ILLICIT DISCHARGE <br /> ❑ SHORELINE/STREAMBANK STABILIZATION <br /> 6. Project purpose(Check all that apply): <br /> �`SINGLE FAMILY HOME ❑ NIULTI FAMILY RESIDENTIAL(apartments) <br /> ❑ ROAD CONSTRUCTION ❑ COMMERCIAL or INSTITUTIONAL <br /> ❑ UTII.,ITIES O SUBDIVISIONS(include number of lots) <br /> ❑ DREDGING ❑ LANDSCA.PING(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: <br /> 9. Project Timeline: Start Date: �_��r /S Completion Date: 3— I- J� <br /> Permits have been applied for: City�County �MN 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 familiaz 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,a11 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 /> admini ive,civil and/or criminal penalties. <br /> . �'z�-�s <br /> Signa e ofEac Property Owner Date <br /> l2evised 7,'(�i 1� Fj:,:��= 1 of 1 <br />