Laserfiche WebLink
' , �, � , <br /> , � Print Form <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 RE UIRED AUTHORIZATIONS BEFORE BEGINNING WORK. <br /> 1. Name of each property owner: W1 �k.� V a+�-Y o <br /> Mailing Address: _lP � 3 3 v����.• ot a12 I�� City: � •��-� 5 ro� State: �IM�Zip: SS 3 �l <br /> Email Address: lM �,,..� o Q <oH„�as�• N� Phone: l0 1�. � 3/v-79SS Fax: <br /> 2. Property Owner Representative Information( ot re uired (licensed contractor,architect, engineer,etc...) <br /> Business Name: (U�a.,r�� 0• � ��`� 4�S C vs����p�esentative Name: J�a^'� �J•����.w�S <br /> Business Address: P-o- (�o X ,2�Sf! City: C'x 4�S%a� State: �> Zip: `s s33/ <br /> EmailAddress: ,ti�orlc.(�.v.d�:11;a�,.s1-•ow�as•��u-� Phone: b�J�..-J�SI� `3�Sc� Fax: <br /> 3. Project Address: �� 3 S' Q�v-� U;r...� oQr. City: o rov�o <br /> State: �� Zip: ss Qtr Secrion(s): Section(s): Township(s): Range(s): <br /> Lot: � Block: Subdivision: P� v�< J;�� piD: ,2 g --I i X- ,t3 --y,L -�oo g <br /> 4. Size of project parcel(square feet or acres): lp a c v-e S <br /> Area of disturbance (square feet): ^�, oa o Volume of excavation/fill(cubic yards): (o OC� Q� fo <br /> Area of existing impervious surface: � Area of proposed impervious surface: <br /> Length of shoreline affected(feet): Waterbody(&bay if applicable): <br /> 5. Type of permit being applied for(Check all that apply): <br /> � EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES <br /> ❑ FLOODPLAIN ALTERATION ❑ STORMWATER MANAGEMENT <br /> ❑ WETLAND PROTECTION ❑ APPROPRIATIONS <br /> ❑ DREDGING ❑ ILLICIT DISCHARGE <br /> ❑ SHORELINE/STREAMBANK STABILIZATION <br /> 6.Project purpose(Check all that apply): <br /> �SINGLE FAMILY HOME ❑ MULTI FAMILY RESIDENTIAL(apartments) <br /> ❑ ROAD CONSTRUCTION ❑ COMMERCIAL or INSTITUTIONAL <br /> ❑ UTILITIES ❑ SUBDIVISIONS(include number of lots) <br /> ❑ DREDGING ❑ LANDSCAPING(pools,berms,etc.) <br /> ❑ SHORELINE/STREAMBANK STABILIZATION ❑ 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: �o f`'� Completion Date: �////S <br /> Permits have been applied for: City�County ❑MN Pollution Control Agency ❑DNR ❑COE � <br /> Permits have been received: City County—�MN Pollution Control Agency—�DNR�COE—� <br /> By signing below,I hereby request a permit to authorize the acrivities described herein.I certify that I am familiar with MCWD <br /> Rules and that the proposed acrivity 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,ail information is true,complete and accurate. I <br /> understand that proceeding with work before all required authorizarions are obtained may be subject to federal,state and/or local <br /> administrati ,civ� and/or criminal enalties. 1 /� <br /> � v <br /> ��i/� y <br /> Signa e o ach P rty Owner Date <br />