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h I� Print Form s • < -__----- --._.--..._._� WATER RESOURCE PERMIT APPLICATION—COMBINED JOINT NOTIFICATION FORM Use this form to notify/apply to the Minnehaha Creek Watershed District(MCWD),their engineering consultants,and the DNR of a proposed project or work which may fall widun their jurisdiction. These agencies should advise you of theu jurisdiction or permit requirements within 10 days.Fill out tlus form completely and mail with your site plar►,maps,etc...to the MCWD, 18202 Minnetonka Boulevard,Deephaven,MN 55391.Keep a copy for your records. YOU MUST OBTAIN ALL REQUIRED AUTHORIZATIONS BEFORE BEGINNING WORK. 1.Property Owner Name(First,Last): " '"" . � . . ddr-ess: � �1��f}l�-B�$_-- ---�tate: --�' '" -- —__ ------- a�g-�4 5-AIC�-e►��----��-----------�' � -�� Email Addre�s: Phone: Fax: 2.Location of proposed project(Attach map with directions to site): Project Address: �7� Q}t.�=a�� ;�,� City: County: ��i� Qtr Section(s): Secrion(s): Township(s): Range(s): Lot: 2 Block: Subdivision: S.'7�tlWS �Ab�/% PID: 3.Size of site: �1',3fp '- Area of disturbance: square feet, or acres Volume of excavation(or fill): cubic yards Length of shoreline affected: c� feet Area of existing impervious surface: Area of proposed impervious surface: 4.Type of permit being applied for(Check all that apply}: � EROSION CONTROL �WETLAND ALTERATION � STORMWATER MANAGEMENT �WATERBODY CROSSING � FLOODPLAIN ALTERATION 0 SHORELINE/STREAMBANK IMPROVEMENTS � DREDGING � O'TI�R ES CRIBE): 5.Project Purpose(Check a11 that apply): � SINGLE FAMII.,Y HOME �MiILTI FAMII,Y RESIDENTIAL HOUSING(apartments,etc. COMNIERCIAL CONSTRUCTION �INSTIT'UTIONAL CONSTRUCTION(churches, schools, etc.) � ROAD CONSTRUCTION �SUBDIVISIONS(include number of lots) � UTII.,ITIES �LANDSCAPING(pools,berms,etc.) 0 DREDGING ❑SHORELINE STABILIZATION(lakescaping,bioengineering) � OTI-�R(DESCRIBE): 6.NPDES/SDS General Stormwater Permit number(if licable): 7.Alternatives(Describe any other sites or meti�ods that could be used to avoid or minixnize impacts to water bodies to achieve die project purposed.Attach additional sheet if needed.) 8.Pro'ect Timeline: Start Date: � Completion Date: • fC. ' � 9.Applicants Representative(Licensed contractor, engineer, etc...) Business Name:�,�j"�� j�j. ��G, Representative Name: • ` � Business Address: �0'73 f�/�rZ.i�9 ° JJ • � City: ldq/�i L��. State:A�.t� Zip: "'��'' r` Email Address:-� He flunrrct r Phone: Z - �S- �" Fa�c: 9sZ-�75'-b"7'78 - 10.Names and addresses of adjoining property owners(Attach list if necessary): cw •� `�A-��. s�� ,rfr�/ Z5' � � c.,` S ' � Permits have been applied: City�County � MN Pollution Control Agency_�DNR�_COE�_ Permits have been received:Ci � County � MN Pollution Control A ency � DNR � COE I hereby notify the recipients of this form of die project proposed herein and request I be advised of any permits or other determinations concerning dus project that I rnust obtain.I understand that proceeding with work before all required authorizations are obtain ay b subject er ,3tate and/or local administrative,civil and/or criminai pe�ialties. 5-c�''- (3 Si a e ofPr e er Date Page 1 of 2