Water Resource Permit Application - Combined Joint Notification Form

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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 within their jurisdiction. These agencies should advise you of their jurisdiction or permit
requirements within 10 days. Fill out this form completely and mail with your site plan, 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):_____________________________________________________________
Mailing Address:_______________________________ City:_________________ State:_______ Zip:________
Email Address:
Phone:
Fax: ____________________
2. Location of proposed project (Attach map with directions to site):
Project Address:__________________________________ City: _______________________________________
County:__________________ Qtr Section(s):______ Section(s): ______ Township(s): ______ Range(s): ______
Lot:
Block:
Subdivision:
PID: ____________________________
3. Size of site: __________________
Area of disturbance: ______________ square feet, or __________ acres
Volume of excavation (or fill): __________ cubic yards
Length of shoreline affected: _________ 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
SHORELINE/STREAMBANK IMPROVEMENTS
DREDGING
OTHER (DESCRIBE):
5. Project Purpose (Check all that apply):
SINGLE FAMILY HOME
MULTI FAMILY RESIDENTIAL HOUSING (apartments, etc.)
COMMERCIAL CONSTRUCTION
INSTITUTIONAL CONSTRUCTION (churches, schools, etc.)
ROAD CONSTRUCTION
SUBDIVISIONS (include number of lots)
UTILITIES
LANDSCAPING (pools, berms, etc.)
DREDGING
SHORELINE STABILIZATION (lakescaping, bioengineering)
OTHER (DESCRIBE):
6. NPDES/SDS General Stormwater Permit number (if applicable): ____________________________________
7. Alternatives (Describe any other sites or methods that could be used to avoid or minimize impacts to water
bodies to achieve the project purposed. Attach additional sheet if needed.)
___________________________________________________________________________________________
8. Project Timeline: Start Date: _________________ Completion Date: _________________
9. Applicants Representative (Licensed contractor, engineer, etc…)
Business Name:______________________________ Representative Name:_____________________________
Business Address:____________________________ City: __________________ State:_____ Zip:___________
Email Address: ______________________________ Phone: ________________ Fax: ____________________
10. Names and addresses of adjoining property owners (Attach list if necessary):
___________________________________________________________________________________________
___________________________________________________________________________________________
Permits have been applied: City _____ County ____ MN Pollution Control Agency_____ DNR_____ COE_____
Permits have been received: City ____ County ____ MN Pollution Control Agency_____ DNR_____ COE_____
I hereby notify the recipients of this form of the project proposed herein and request I be advised of any permits or other
determinations concerning this project that I must obtain. I understand that proceeding with work before all required authorizations
are obtained may be subject to Federal, State and/or local administrative, civil and/or criminal penalties.
__________________________________________________
______________________________
Signature of Property Owner
Date
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