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/0..36 5 1 <br /> JUN 2 9 2016 <br /> WATER RESOURCE PERMIT APPLICATION FORT RRvV <br /> Use this form to notify/apply to the Minnehaha Creek Watershed District(MCWD)of aproposed pro$ dr <br /> their jurisdiction.Fill out this form completely and submit with your site plan,maps,etc.to me Dac.W.0 <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: (i wc. Ack,1 n n <br /> Mailing Address: 4S4c 11-<1 L w- 1)rtk Al City: 'Medina State: MN Zip:'i'5 '40 <br /> Email Address: acklm ann & a-rat a.com Phone: 743-4-VC 620 3 Fax: <br /> 2.Property Owner ' -•resentative Information(not required)(licensed contractor,architect,pngineer,etc.,.) <br /> Business Name: r Its d. 6n.1a Representative Name: L•11 eSvv <br /> Business Address: /CoSv Z3 Ave . City: f/t rtw✓'t, State: Mg Zip:4-9P4-7„ <br /> Email Address: . i;st QGkarisscvd•• ow. Phone: b t1 •-35'5--/73'7 Fax: a/2.-6o 1-239. <br /> 3.Project Address: V //7 S" 7Ylconu./ L ke. be. City: Orono <br /> State: MN Zip: 55'3'( Qir Section(s): Section(s): Township(s): Range(s): <br /> Lot 8 Block: ( Subdivision: 7 laer+a./ Lake Preserve. PID: zs- /I8-23 44 oa 1-7 <br /> 4. Size of project parcel(square feet or acres): (34,9 Z B sq. . <br /> Area of disturbance(square feet): 2 t,eo Vobime of excavation/fill(cubic yards):' /0/1 <br /> Area of existing impervious surface: NM Area of proposed impervious surface: /'f,258a <br /> Length of shoreline affected(feet): N/A Waterbody(&bay if applicable): 'Moon", LsL C&tel» IL) <br /> 5.Type of permit being applied for(Check all that apply): <br /> $ EROSION CONTROL 0 WATTRBODY CROSSINGS/STRUCTURES <br /> ❑ FLOODPLAIN ALTERATION 0 STORMWATER MANAGEMENT <br /> ❑ WETLAND PROTECTION 0 APPROPRIATIONS <br /> ❑ DREDGING C! ILLICIT DISCHARGE <br /> ❑ SHORELINE/STREAMBANK STABILIZATION <br /> 6.Project purpose(Check all That apply): <br /> ❑ SINGLE FAMILY HOME 0 MULTIFAMILY RESIDENTIAL(apartments) <br /> ❑ ROAD CONSTRUCTION 0 COMMERCIAL or INSTITUTIONAL <br /> ❑ UTILITIES 0 SUBDIVISIONS(include number of lots) <br /> ❑ DREDGING , ❑ LANDSCAPING(pools,berms,etc.) <br /> ❑ SHORELINE/STEAMBANK STABILIZATION 0 OTHER(DESCRIBE): <br /> 7.NPDES/SDS General Store water Permit Number(if applicable): M/A <br /> 8.Waterbody receiving runoff from site: 7Koaray L44.4 — RvIewitc, Fb+d <br /> 9.Project Timeline: Start Date: %/„/sp 2oib , Completion Date: t/i,, 7417 <br /> Permits have been applied for:City X County MN Pollution Control Agency DNR COE <br /> Penults 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 all required authorizations are obtained may be subject to federal,state and/or local <br /> administrative,ci ' and/or criminal penalties. <br /> k6 -Z-/ I L <br /> Signature of Each Property Owner • - -. - - - . . - • •• --. Date <br /> • <br /> Revised 7/15/13 Page 1 of 1 <br />