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WATER RESOURCE PERMIT APPLICATION FORM Use this form to notify/apply to the Minnehaha Creek Watershed District(MCWD)of a proposed project or work which may fall within their jurisdiction.Fill out this form completely and submit with your site plan,maps,etc.to the MCWD at: 15320 Minnetonka Blvd.Minnetonka,MN 55345. Keep a copy for your records. YOU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. 1.Name of each property owner:Alica/Tom Codute Mailing Address: 2535 Old Beach Rd. City: Orono State: MN Zip: 55392 Email Address: codutehome@gmaii.com Phone: 952-471-7559 Fax: 2. Property Owner Representative Information(not required) (licensed contractor, architect, engineer, etc...) Business Name: Custom Pools Inc. Representative Name:Jan Blount Business Address: 8960 Excelsior Blvd City: Hopkins State: MN Zip: 55343 Email Address:lan@custompoolsinc.com Phone: 952-933-2255 Fax:952-933-2259 3. Project Address: 2535 Old Beach Rd. City: Orono State: MN Zip: 55343 Qtr Section(s): Section(s): Township(s): Range(s): Lot: 6 Block: 1 Subdivision: The Marsh@LaFayette PID: 4. Size of project parcel (square feet or acres): 840 Area of disturbance (square feet): 840 Volume of excavation/fill (cubic yards):186 Area of existing impervious surface: 10,238 Area of proposed impervious surface: 12,234 Length of shoreline affected (feet): n/a Waterbody(&bay if applicable): n/a 5. Type of permit being applied for(Check all that apply): 2 EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES ❑ FLOODPLAIN ALTERATION ❑ STORMWATER MANAGEMENT ❑ WETLAND PROTECTION ❑ APPROPRIATIONS ❑ DREDGING ❑ ILLICIT DISCHARGE ❑ SHORELINE/STREAMBANK STABILIZATION 6.Project purpose(Check all that apply): * SINGLE FAMILY HOME ❑ MULTI FAMILY RESIDENTIAL(apartments) ❑ ROAD CONSTRUCTION ❑ COMMERCIAL or INSTITUTIONAL ❑ UTILITIES ❑ SUBDIVISIONS(include number of lots) ❑ DREDGING ❑ LANDSCAPING(pools,berms,etc.) ❑ SHORELINE/STREAMBANK STABILIZATION ❑ OTHER(DESCRIBE): 7.NPDES/SDS General Stormwater Permit Number(if applicable): 8. Waterbody receiving runoff from site:Lake Minnetonka 9. Project Timeline: Start Date: 5/15/17 Completion Date: 6/30 Permits have been applied for: City XCounty MN Pollution Control Agency DNR COE 13 Permits have been received: City �County--n MN Pollution Control Agency DNR COE -70 By signing below,I hereby request a permit to authorize the activities described herein.I certify that I am familiar with MCWD Rules and that the proposed activity will be conducted in compliance with these Rules.I am familiar with the information contained in this application and,to the best of my knowledge and belief,all information is true,complete and accurate. I understand that proceeding with work before all required authorizations are obtained may be subject to federal,state and/or local administrative,civil and/or 'minal penalties. 4 � (-1 Si afore of Each Property Owner Date Revised 7/15/13 Page I of I