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Dane County For Office•Use Only=Revised 01.13 2016 <br /> Erosion Control Permit .Permit Number' aa, ' <br /> Simplified Application <br /> (Application must be made in person. Received &Approved Sy. Date_ <br /> Incomplete applications will not be accepted.) <br /> This form may only be used for the following projects: <br /> 1. Land disturbing activities meeting the criteria of DCCO s. 14.50(2) <br /> 2. Land disturbing activities occurring in the Shore)jand Zone meeting the criteria of DCCO s. 11.05(2)(b)or(d) <br /> Please see Dane County Code of Ordinances'ifor the complete list of qualifying criteria. <br /> Project Name: lA-USitio] Applicant Information(Individual making in-person application) <br /> Landowner Name(s): Msc.Ls4,4- Applicant Name: <br /> Landowner Address: -5/7k --Y' . ry 1-401/r)&v. Applicant Address: <br /> Landowner Phone: hoe -17_5 -04 2 ' Applicant Phone: <br /> Landowner E-mail: pplicani E-mail: <br /> J Sh or r l=a`n <br /> d Erosion Control(SE) <br /> Type of Permit: Erosion Control <br /> (che ck <br /> only one) E <br /> Municipality: SUrJ P \2- E Sec ©; Quarter l Parcel Number (28 I I - ?Ca -618 O-O <br /> Fee Calculation µ <br /> Total Disturbed Area.......................... <br /> Total New Impervious...-.••••• ••• •........••••••••• ft` <br /> (includes gravel) Base Fee $ 100 . 00 <br /> Total Fee=$ 100 . 00 <br /> Notes: <br /> 1.All requirements included in this application corresppnd 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(5)(a)3 or 1-.49(4)(c)). <br /> 3. Late filing fee: The permit fees •I be doubled wh=re w221k as beg before a permit has been obtained(s. 11.50(7)or <br /> 14.55(2)(b)). <br /> Applicant Signatur-. `.L4• �,I �/` Date: 3-7,z- ( 3. <br /> If the person submitting the application is not th 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 to: <br /> Water Resource Engineering Division, 5201 Fen Oak Drive, Room 208, Madison, WI 53718 <br />