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Dane C 0 u n ty LCR office use only Revised 1.13.09 <br /> Erosion Control & Stormwater Permit Number: SE GOO9 -6V965 <br /> Management Permit Application Date: //-<3 -01 <br /> (Incomplete applications will not be accepted) <br /> Project Name: t" \e G CP Applicant Information <br /> (Individual ual making in-person application) <br /> n) <br /> Landowner Name(s): Pat) t‘/ L O!f l u A ea (P Applicant Name: &/1 ( I\d h< i PV✓'47 e e (/T� <br /> B"� S 9 l <br /> Landowner Address: ),,, ,.c--f fill i [ l t ct on s /9,i t IQci'rApplicant Address: t fr 3 f/ � /)..."i t i c_ <br /> K c( ■ rf I i 5-3 69' F-s G ci Ss4 � t&)i c3`r'3 tf <br /> Landowner Phone: r",/1c-*-- ,g-9/— 3 f( ( Applicant Phone:60 s- — 33(7-70-1?-- K X_93o <br /> Landowner E-mail: /t6 Applicant E-mail: £rOtA G 4-fCif is C e How,' s , Co <br /> Name and company of engineer/consultant who prepared the plans: 1 (l✓i? C e f c(Q . <br /> Type of Permit: Erosion Control Only Stormwater Management Only Erosion Control&Stormwater <br /> (check only one) I I (EC )( SM) I I Management(ES) <br /> Fey Shoreland Erosion Control Only I Shoreland Erosion Control & <br /> (SE) Stormwater Management(SS) <br /> Municipality: l /rct Sa',c s-p J s vt 5 Section: / r Quarter:1V -A/I'd Parcel#:10 14 e)��j)r 19/-3F-6-6- <br /> Fee Calculation(all projects must include disturbed area and new impervious,even if not subject to fee as noted by brackets)7 <br /> Total Disturbed Area...[EC,ES,SE,SS] r" )` ft2x$0.005/ft2 =$ N- 7(° <br /> Total New Impervious...[ES,SM,SS] q S" a ft2x$0.010/ft2 =$ <br /> (includes gravel) ,, <br /> Total Redevelopment Impervious...[ES,SM,SS] ///��-- ft2x$0.005/ft2 = $ <br /> (includes gravel) <br /> Base Fee: $200-EC or SE meeting criteria in Ch. 11.05(2)(c); $400- ES, SM, SE, or SS Base Fee= $ (ROO ' QO <br /> 1 . <br /> Total Fee=$ "(I" 76 <br /> Notes: <br /> 1. Be sure to clearly indicate the extent(limits)and size (ft2) of all disturbed and impervious areas on your plan <br /> 2.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 /> 3. 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(4)c or 11.05(5)(a)3 DC Code of Ordinances) <br /> Applicant Signature: C\�a�----. Date: 11-`?)- l' 1 <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 a landowner's agent must be attached <br /> Permit Received by: Date: // :3 -09 <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 Land Conservation, 1 Fen Oak Ct, Room 208, Madison, WI <br />