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Dane County For Office Use Or*-Revised 01.08.2014 <br /> Stormwater Management Permit Number:. <br /> Permit 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: 10 216 Highway 14 Applicant Address: 10 216 Highway 14 <br /> Mazomanie, WI 53560 Mazomanie, WI 53560 <br /> Landowner Phone: (608) 963-9109 Applicant Phone: (608) 963-9109 <br /> Landowner E-mail: PCI ohn @mhtc .net Applicant E-mail:pCI ohn @mhtc .net <br /> Name and company of engineer/consultant who prepared the plans:.Aaron Falkosky; Quam Engineering, LLC <br /> Municipality:Town of Mazomanie Section 12 s Quarter-SE Parcel#: 0806-154-9280-1 <br /> Latitude/Longitude: 4 3 . 16 2 5 6 3 <;. / 49 . 765557 <br /> Lat/long location should be the coordinates pt the center of the site es defined in the plan Decimal <br /> coordinates to 6 places required. (e.g. 43 055978 -89L290669) , <br /> Fee Calculation <br /> Total New Impervious Area ........... 5% 5 b 0'" ft2 x$0.010/ft2=$ 55 . 60 <br /> (includes gravel) <br /> 3.; 099 <br /> Total Redeveloped Impervious Area ............... ft2 x$0.005m2 =$ 15 . 50 <br /> (includes gravel) <br /> Total Impervious Added Since 8/22/01 ............................... <br /> Base Fee:$400 Base Fee=$400 . 00 <br /> Total Fee=$ 471 . 10 <br /> Notes: <br /> 1.All requirements included in this application correspond to the requirements set forth in Chapter 14 of the Dane County Code of <br /> 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. 14.49(4Xc)). <br /> 3.Late filing fee: The permit fee II a do led where work has begun before a permit has been obtained(s. 14.55(2)(b)). <br /> Applicant Signature: _ ebir Date: �V/6� <br /> If the person submitting pplication is not the landowner,a notarized statement authorizing the applicant to act as the <br /> landowner's agent must b ttached. <br /> This application must be submitted in person (M-F, 8 A.M. —4 P.M.) <br /> with two copies pf all permit materials &fees to: <br /> Water Resource Engineering Division, 5201 Fen Oak Drive, Room 208, Madison, WI 53718 <br />