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Dane County For Office Use Only—Revised 01.08.2014 <br /> Erosion Control Permit Permit Number: <br /> Application Application Received By: Date; <br /> (Application must be made in person. Application Approved By: Date: <br /> Incomplete applications will not be accepted.) <br /> Associated Permits: <br /> Project Name: Premier Co-op 2015 Grain Bin Applicant Information(Individual making in-person application) <br /> Landowner Name(s): Premier Co-op Applicant Name: Premier Co-op <br /> Landowner Address: 10216 Highway 14 Applicant Address: 10216 Highway 14 <br /> Mazomanie, WI 53560 Mazomanie, WI 53560 <br /> Landowner Phone: (608) 963-9109 Applicant Phone: (6 0 8) 963-9109 <br /> Landowner E-mail: PCI ohn @mhtc .net Applicant E-mail:pcj ohn @mhtc .net <br /> Name and company of engineer/consultant who prepared the plans: Aaron Falkosky; Quam Engineering, LLC <br /> Type of Permit: m Erosion Control Shoreland Erosion Control <br /> (check only one) (EC) I (SE) <br /> Municipality:Town of Mazomanie S406: 1,5 Quarter:SSE Parcel#: 0 8 0 6-154-92 80-1 <br /> Fee Calculation(all projects must include disturbed are and new Impervious area) <br /> Total Disturbed Area.......................... ..` 2 5, 0 0 0- ft2 x$0.005/ft2 =$ 125 . 00 <br /> Total New Impervious Area ............ .; 5 >56 ft2 <br /> (includes gravel) <br /> Total Redevelopment Impervious Area ........... ..................... . 3 0 9 9 ft2 <br /> (includes gravel) <br /> Base Fee:Erosion Control(EC) $200 OR Shoreland Erosion Control(SE)$400 Base Fee=$ 2 0 0 . 0 0 <br /> ❑Check box to apply$200 base fee for Shoreland Erosion Control <br /> (SE)projects meeting criteria in s.11.05(2)(c) 325 . 00 <br /> Double Fob Total Fee=$ <br /> Notes: <br /> 1.All requirements included in this application correspond to the requirements set forth in Chapters 11 and/or 14 of the Dane <br /> County Code of Ordinances. <br /> 2.By submitting this application, permittee and landowner permit Dane County staff to enter project property for inspection and/or <br /> curative action(s. 11.05(5Xa)3 or 14.49(4Xc)). <br /> 3.Late filing fee: The permit fee shall be doubled where work has begun before a permit has been obtained(s. 11.50(7)or <br /> 14.55(2xb)). <br /> Applicant Signature; 24L Date: 773 <br /> If the person submitting the pplication is not the landowner,a notarized statement authorizing the applicant to act as the <br /> landowner's agent must be ttached. <br /> This application must be submitted in person (M-F, 8 A.M. -4 P.M.) <br /> with two copies of all permit materials &fees to: <br /> Water Resource Engineering Division, 5201 Fen Oak Drive, Room 208, Madison, WI 53718 <br />