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Dane County For Office Use Only—Revised 01.08.2014 <br /> Erosion Control Permit Permit Number ,9015. -0451 <br /> Simplified Application ^ <br /> (Application must be made in person. ,Received&Approved By: Tt"S Date:\p2/F/\ S <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: Copus Driveway Applicant Information(Individual making in-person application) <br /> Landowner Name(s):Mark & Kerry Copus Applicant Name:Mark Copus <br /> Landowner Address: 240 USH 14 Applicant Address: 240 USH 14 <br /> Brooklyn, WI 53521 Brooklyn, WI 53521 <br /> Landowner Phone: (6 0 8) 445-0598 Applicant Phone: (6 0 8) 445-0598 <br /> Landowner E-mail: bowhuntermark @gmail corn. ,.Applicant E-mail: bowhunter'rark @grnail . com <br /> Type of Permit: IN Erosion Control (EC) Shoreland Erosion Control (SE) <br /> (check only one) <br /> Municipality: Town of Rutland - Section:_ 29 Quarter: SE - Parcel Number: 0510-294 -8020-0 <br /> Fee Calculation <br /> Total Disturbed Area............................ 20-, 0.0 0 -' ft` <br /> Total New Impervious 13, 800 ft` <br /> (includes gravel) Base Fee=$ 100 . 00 <br /> Total Fee=$ 10 0 . 0 0 <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(5)(a)3 or 14.49(4)(c)). <br /> 3. Late filing fee: The permit fee shall be doubled where work has begun before a permit has been obtained(s. 11.50(7) or <br /> 14.55(2)(b)). <br /> Applicant Signature: _ 60 46 i Date: 12/08/15 <br /> If the person submitting the application is no 'e 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 />