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- ::EiVED <br /> , t\Y 1 8 2016 <br /> C. :'.' CF ORONO <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 /> I.Name of each property owner: LoicE jEbeta-1.4 toe.-V-E.40cAtSLE.- TR-UST" <br /> Mailing Address: '3 el S E -s, .) Av„,-C City: Al jatiAeGi If State: A‘A) Zip: sT4oR <br /> Email Address: lbettnIckeomailcom Phone: g i2- &I-30101 Fax: <br /> 2,Property Owner Representative Information(not required)(licensed contractor,architect,engineer,etc...) <br /> Business Name: Stonewood, LLC Representative Name: Nate Mitchell <br /> Business Address: 153 Lake Street East City: Wayzata State: MN Zip: 55391 <br /> Email Address: nateagstonewood.comFax:952-697-5591 <br /> Phone: 512-462-4000 <br /> 3.Project Address: 1380 Orono Late City: Orono <br /> Stale; MN Zip: 55391 Qtr Section(s): Section(s): Township(s): Range(s): <br /> Lot: Block: Subdivision: pm: 02-117-23-34-0012 <br /> 4.Size of project parcel(square feet or acres): i I 44 cet--i-• <br /> / <br /> Area of disturbance(square feet): -45 b 0 Volume of excavation/fill(cubic yards): I\OO <br /> Area of existing impervious surface: t 0 f.,o3 Area of proposed impervious surfsice: <br /> Length of shoreline affected (feet) I 1g Waterbody(&bay if applicable): Ly... frbiurtv.74 PrvA/11341 <br /> 5.Type of permit being applied for(Check all that apply): <br /> g EROSION CONTROL 0 WATERBODY CROSSINGS/STRUCTURES <br /> O FLOODPLAIN ALTERATION 0 STORMWATER MANAGEMENT <br /> D WETLAND PROTECTION D APPROPRIATIONS <br /> O DREDGING 0 ILLICIT DISCHARGE <br /> El SHORELINE/STREAMBANK STABILIZATION <br /> 6.Project purpose(Check all that apply): <br /> ya SINGLE FAMILY HOME 0 MULTI FAMILY RESIDENTIAL(apartments) <br /> D ROAD CONSTRUCTION 0 COMMERCIAL or INSTITUTIONAL <br /> O UTILITIES 0 SUBDIVISIONS(include number of lots) <br /> O DREDGING 0 LANDSCAPING(pools,berms,etc.) <br /> O SHORELINE/STREAMBANK STABILIZATION 0 OTHER(DESCRIBE): <br /> 7.NPDES/SDS General Stormwater Permit Number(if applicable) _ ______ <br /> 8.Waterbody receiving runoff from site: 1,A-K.I Ail iksijrrvivpLA— . _ <br /> 9.Project Timeline: Start Date: S•13. 1 6 Completion Date:_.3.1. 1.3- <br /> Permits have been applied for: City zo El County 0 MN Pollution Control Agency 0 DNR 0 COE 0 <br /> Permits have been received: City in County—0 MN Pol lution Control AgencyCI DNR-0 COE-0 <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 arc obtained may be subject to federal,state and/or local <br /> administrati e,ci II and/ criminal .enal'es. <br /> ... <br /> / <br /> Signature of EaellProperty Owner Date <br /> op ik,,,.. LAkt. ?4eli,%1Ck.- kevoc4oke sit'....i4" <br /> Revised 7/15/13 Page 1 of I <br />