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34rg; <br /> (1)600 <br /> .11N 2 3 2016 <br /> WATER RESOURCE PERMIT APPLICATION FORM <br /> Use this form to notify/apply to the Minnehaha Creek Watershed District(MCWD)of a proposed project arc, 1,� y fall within <br /> their jurisdiction.Fill out this form completely and submit with your site plan,maps,etc.to the i aE'' <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: David Klema and Julia Shaver <br /> Mailing Address: 40 Orono Orchard Rd City: Orono State: MN Zip: 55391 <br /> Email Address: david.klema@gmail.com Phone: 617-461-2395 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: 40 Orono Orchard Rd City: Orono <br /> State: MN Zip: 55391 Qtr Section(s): SW Section(s): 35 Township(s): 118N Range(s): 23W <br /> Lot: 009 Block: 007 Subdivision: Orono Oaks ND: 3511823340005 <br /> 4. Size of project parcel (square feet or acres): 2.82 acres <br /> Area of disturbance(square feet): 3,000 Volume of excavation/fill (cubic yards):150 <br /> Area of existing impervious surface: 1,500 Area of proposed impervious surface: 0 <br /> Length of shoreline affected(feet): Waterbody(&bay if applicable): <br /> 5. Type of permit being applied for(Check all that apply): <br /> IZ EROSION CONTROL 0 WATERBODY CROSSINGS/STRUCTURES <br /> ❑ FLOODPLAIN ALTERATION 0 STORMWATER MANAGEMENT <br /> ❑ WETLAND PROTECTION 0 APPROPRIATIONS <br /> ❑ DREDGING 0 ILLICIT DISCHARGE <br /> ❑ SHORELINE/STREAMBANK STABILIZATION <br /> 6. Project purpose (Check all that apply): <br /> ❑ SINGLE FAMILY HOME 0 MULTI FAMILY RESIDENTIAL(apartments) <br /> ❑ ROAD CONSTRUCTION 0 COMMERCIAL or INSTITUTIONAL • <br /> ❑ UTILITIES 0 SUBDIVISIONS (include number of lots) <br /> ❑ DREDGING CI LANDSCAPING(pools,berms,etc.) <br /> ❑ SHORELINE/STREAMBANK STABILIZATION 0 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: ASAP Completion Date: 09/15/2016 <br /> Permits have been applied for: City 0 County 0 MN Pollution Control Agency 0 DNR 0 COE <br /> Permits have been received: City--❑County– 0 MN Pollution Control Agency DNRD 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 proceedin:with work before all required authorizations are obtained may be subject to federal,state and/or local <br /> ad' ristrative, ivil ay %criminal penalties. <br /> 465100/4 <br /> rgnature of Each 'roperty Owner D to <br /> Ilia ised .i l 13 <br />