Laserfiche WebLink
Dane County zoning office use only <br /> Non-Metallic Mining Reclamation Permit#: <br /> Permit Application Date: <br /> Landowner: TAN N 1 ( (n Agent: <br /> Address: U✓-k - rn Address: <br /> e «LC aatNS ( D s `�sS2 <br /> Phone: c �-. 2(9 --'9 Phone: <br /> E-mail: E-mail: <br /> Address of site: 24-co <br /> (may need to be assigned) <br /> f <br /> Township: e <br /> Parcel#: 0 ZTZ �SOZ —d Parcel#: <br /> Parcel#: Parcel#: <br /> Parcel#: Parcel#: <br /> Parcel#: Parcel#: <br /> Type of aggregate: L tm. t Total site acreage: J' <br /> Plan review fees: <br /> (Less than one acre:NO FEE, 1 to 25 acres:$875.00,25 to 50 acres:$1,100.00,More than 50 acres:$1,300.00) <br /> Non-conforming: Yes or No Conditional use permit#: <br /> Effective Date: <br /> Expiration Date: <br /> Erosion control/Stormwater permit#: ES- 2004 - a zz ` Expiration Date: <br /> I hereby request on behalf of the applicant a non-metallic mining permit. I certify,as aduly authorized representative or agent that the <br /> operator listed above will comply with the statewide non-metallic mining reclamation standards established in ss.NR 135.05 through <br /> NR 135.15,Wis.Adm.Code. The applicant agrees to provide to Dane County an annual fee as established by county ordinance and <br /> site access for county officials necessary to evaluate this application and ensure compliance with a permit. Also,financial assurance <br /> standards as established in Ch.74141 od Dane County Code of Ordinances. <br /> Applicant signature: r^^r3 `'—'�`�— Date: r ` ✓� I <br /> If the person applying(submitting the application in-person,at the counter)is not the landowner,a notarized statement <br /> authorizing the applicant to act as the landowner's agent must be attached. <br /> Permit received by: Date: <br /> Permit reviewed by: Date: <br /> This application must be submitted in person M - F, 8 A.M. -4 P.M., <br /> with two copies of all permit materials to: <br /> Dane County Zoning, 210 Martin Luther King Jr. Blvd. Room 116, Madison,WI <br />