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MAY-27-2008 10:59 <br /> OrP.02iO3 <br /> e <br /> WATER RESOURCE PERMIT APPLICATION— COMBINED JOINT NOTIFICATION FORM <br /> Use this form to notify/apply to the Minnehaha Creek Watershed District(MCWD),their engineering consultants,and the DNR of a <br /> proposed project or work which may fall within their jurisdiction.These agencies should advise you of their jurisdiction or permit <br /> requirements within 10 days.Fill out this form completely and mail with your site plan,maps,etc...to the MCWD, 18202 Minnetonka <br /> Boulevard,Deephaven,MN 55391.Keep a copy for your records. <br /> YOU MUST OBTAIN ALL RE•UIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1. Property Owner Name (First, Last): C' d ©re) 0 <br /> Mailing Address: T3ox y <br /> Email Address: � City: Cr �S- gate:_ yY/ <br /> Phone: — r� —8/`lax: Q ._zcy ieg/�. <br /> 2. Location of proposed project(Attach ma• with directions to site): <br /> Project Address: , :v; Z.D. City: Lv )ra:a + <br /> County. ��4 . Qtr Section(s): Section(s): <br /> Lot: Block: Subdivision: ( ) Township(s): Range(s): <br /> ND: <br /> 3. Size of site: % c..e.. Area of disturbance: square feet, or acres <br /> Volume of excavation(or fill): cubic yards Length of shoreline affected: feet <br /> Area of existint impervious surface: ,,t o u Area of ro osed im ervious surface: <br /> 4. lype of permit being applied fbr(Check all that apply): <br /> VEROSION CONTROL L WETLAND ALTERATION <br /> ❑ STORMWATER MANAGEMENT <br /> ❑ WATERBODY CROSSING <br /> C FLOODPLAIN ALTERATION C SHORELINE/STFEAMBANK IMPROVEMENTS <br /> 0 DREDGING <br /> ❑ OTHER(DESCRIBE): <br /> 5. Project Purpose(Check all that apply): <br /> ❑ SINGLE FAMILY HOME U MULTI FAMILY RESIDENTIAL HOUSING(apartments, etc.`) <br /> COMMERCIAL CONSTRUCTION G INSTITUTIONAL CONSTRUCTION(churches, schools,etc.) <br /> ❑ ROAD CONSTRUCTION ❑ SUBDIVISIONS (include number of lots) <br /> • ITITL` IES L LANDSCAPING(pools,berms,etc.) <br /> 0 SHORELINE STABILIZATION(lakescaping,bioengineering) <br /> j OTHER DESCRIBE : r>° , g .. - <br /> 6.NPDES/SDS General Stormwater Permit number(if appliccab�: <br /> 7. Alternatives (Describe any other sites or methods that could be used to avoid or minimize impacts to water <br /> bodies to achieve the project purposed.Attach additional sheet if needed.) Wo <br /> 8. Project Timeline: Start Date: <br /> Completion Date: <br /> 9. Applicants Representative(Licensed contractor, engineeetc...) <br /> Business Name: © v o 6(f Representative Name: g <br /> Business Address: c9v _ l City: (4),„. �� State: Zip: 1- <br /> Email Address: Phone:' 2Y m Fax: T P• _ <br /> 10. Names and addresses of adjoining property owners (Attach list if necessary): <br /> tV <br /> Permits have been applied: City. z/County MN Pollution Control Agency DNR COE <br /> Permits have been received: City County MN Pollution Control Agency DNR COE <br /> I hereby notify the recipients of this form of the project proposed herein and request I be advised of any permits or other <br /> determinations concerning this project that I must obtain.I understand that proceeding with work before all required authorizations <br /> are obtained ma; be— 1r <br /> t. Federal,State and/or local administrative,civil and/or criminal penalties. <br /> or <br /> tit I y <br /> Sig ..tureo='r0 <br /> Date <br /> Page 1 of 2 <br />