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Dane County For Office Use Only-Revised 01.13,, 01p."7-:- <br /> Erosion Control Permit <br /> 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: Lot 1, CSM 1412 3 Applicant Information(Individual making in-person application) <br /> Landowner Name(s): Kenneth & Lindsay Karl s Applicant Name: <br /> Landowner Address: 10795 N. Perry Road Applicant Address: <br /> Blue Mounds, WI 53517 <br /> Landowner Phone: Applicant Phone: <br /> Landowner E-mail: qualitywestinc @qmail .corn Applicant E-mail: <br /> Name and company of engineer/consultant who prepared the plans: Ryan Quam, Quam Engineering, LLC <br /> Type of Permit: Erosion Control Shoreland Erosion Control <br /> (check only one) (EC) (SE) <br /> Municipality:Town of Perry ° Section'. ' Quarter:NW.. Parcel#: 0506-052-8590-0 <br /> Town of Blue Mounds 32 = SW 0606-323-9250-6 <br /> ti a <br /> Fee Calculation(all projects must include'distprbed area and new impervious area), <br /> Total Disturbed Area.. 40 ; 0.430- ft2 x$0.005fft2 =$ 200 . 00 <br /> Total New Impervious Area •. 7-, 500 ft2 <br /> (includes gravel) - C r <br /> Total Redevelopment Impervious Area.......................:::.: ..: s:° 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$200 base fee for Shoreland Erosion Control <br /> (SE)projects meeting criteria in s.11.05(2)(c) 400 . 00 <br /> Doub6 F.a Total Fee=$ <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(4)(c)). <br /> 3. Late filing fee: The permit fee shall be doubl-d where work has begun before a permit has been obtained(s. 11.50(7)or <br /> I4.55(2)(b)). <br /> Applicant Signature: / �� Date: 3-/-/ <br /> APP- <br /> If the person submitting i e application is not the landowner,a notarized statement authorizing the applicant to act as the <br /> landowner's agent must be attached. <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 />