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Dane County For Office Use Only-Revised 03`21.2016 <br /> Erosion Control Permit Permit Number C-, —0 \ .3-4-- <br /> Simplified Application Received&A roved S <br /> (Application must be made in person. Approved y �`� Date. 1442- <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 /> r <br /> Project Name: V/4.S� 190._(:),::s.e�� <br /> Applicant Information (Indivi al making_in-person application) <br /> �J �/ ( r� // 1 l Gi . KC j I(� <br /> Landowner Name(s):ZK-CeG -�'h`Pjf1 Y7;/se Applicant Name: A" -ll 9,Q e_0 4-4O. <br /> a50 6 IMP . <br /> Landowner Address: # Applicant Address: r- • i"i101� s /�� ;_ <br /> ALoe leI 1,0.7-5, --0? fi 0,_e Dr_ewc._5 ze&53_97 <br /> Landowner Phone: 608- 51741-3w/y Applicant Phone: 60(57- 7/o?-(9 `jy <br /> Landowner E-mail: /a L.3 h- /) , y✓hc*J 1 . e 7'7 Applicant E-mail: if-,c7_77 ,e /.z)57' Zi 'e' .. C'.ON7 <br /> Type of Permit: R.Erosion Control (EC) Shoreland Erosion Control (SE) <br /> (check only one) <br /> Municipality:fowto 0(5(/2J> G Jam. Section: Quarter: Parcel Number: <br /> (9(067-0c3 -gs95---o <br /> Fee Calculation <br /> Total Disturbed Area.............................. ........ ...... ... _ O i O ' ft 2 <br /> Total New Impervious \e) aCcD-I-- ft <br /> (includes gravel) <br /> ' Base Fee=$ 1 <br /> �� <br /> Total Fee=$ 1 O LD <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 fe- hall be doubled where work has begun before a permit has been obtained (s. 11.50(7)or <br /> 14.55(2)(b)). //9 7 /� <br /> pplicant Signature �e-fL'�� • Date: 1 o��l�Q <br /> If the person submitting the application is not the landowner, ='tarized 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 />