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---- Da n e County For Office Use Only Revised 0121.2016 <br /> Erosion Control Permit Permit Number <br /> Simplified Application <br /> (Application must be made in person. Received&Approved By: 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 Shoreland Zone meeting the criteria of DCCO s. 11.05(2)(b)or(d) <br /> Please see Dane County Code of Ordinances for the complete list of qualifying criteria. <br /> Project Name: L-X ?Do \CVnC' Applicant Information(Individual making in-person application) <br /> Landowner Name(s): m [Al �_Q Applicant Name: K..!yYl e). <br /> Landowner Address: a: I9 C{LL.ut.ck O Applicant Address: S ' - <br /> eo*O l(ov e )t 5 35 a� <br /> Landowner Phone: (aO$" (?9 ' 1SSb Applicant Phone: 8 <br /> Landowner E-mail: L(2,x hOCS 2 Sh Ce 4%a (YIQ t ` Applicant E-mail: <br /> Type of Permit: JC Erosion Control(EC), El f Shoreland Erosion Control(SE) <br /> (check only one) <br /> Municipality:��PA -+ 3(..0 YC Section:: Quarter Parcel Number Olel\- It 3""S\S0 <br /> Fee Calculation <br /> Total Disturbed Area 20©00�, ft2 <br /> Total New Impervious...........................................:.:.:::..: <br /> 340) +df`X iS f <br /> (includes gravel) /L�[oo Base Fee=$ 10 0 . 0 0 <br /> `� l Total Fee=$ 100 . 00 <br /> Notes: <br /> 1.All requirements included in this application correspond to the requirements set forth in Chapters 11 and/or 14 oflhe Dane <br /> � , °� � � � end/or <br /> o D EIP DATE 3-30- •� No. <br /> L <br /> CC A N <br /> O <br /> RECEIVED FROM KIM Lfi <br /> O ; <br /> v CC t' <br /> rm DJ • ct as the <br /> co <br /> cC Co) Q FOR RENT <br /> C•FOR DAMN COUNT/ Ec, Qremo-ft3G <br /> O 5 ACCOUNT O CASH <br /> cp w CHECK, FROM TO <br /> w U- u) PAYMENT t0 'g, QORDER II 53718 <br /> T <br /> CI BAL.DUE 1111 . di CREDIT BY 3-11 <br />