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Dane County For Office Use Only—Revised 03.21.2016 <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:Hellenbrand Shed Applicant Information (Individual making in-person application) <br /> Landowner Name(s): Ken Hellenbrand Applicant Name: Scott Hellenbrand <br /> Landowner Address: 5240 Church Rd Applicant Address: 5666 USH 12 <br /> Middleton WI 53562 Waunakee WI 53597 <br /> Landowner Phone: (6 0 8) 438-1306 Applicant Phone: (6 0 8) 438-1306 <br /> Landowner E-mail: u :*:/ Apt3l(cadt E-mail: <br /> Type of Permit: ig Erosion Control (EC) i • ±'' Shoreland Erosion Control (SE) <br /> (check only one) r <br /> Municipality: Town of Springf e'JJi section:`15 Quarter: SW Parcel Number: 0 8 0 8-15 3 -9 0 0 0-6 <br /> Fee Calculation ?f 3 tN` ' a " c j �2s k / j O v <br /> Total Disturbed Area 4 - " 2 0 0 0 0 j:' ft2 ( 2/ 1 <br /> 2 <br /> Total New Impervious ,�� V '13 , 000 Base Fee=$ <br /> (includes gravel) 1 0 0 . 0 0 <br /> Total Fee=$ 100 . 00 <br /> Notes: j 5� <br /> 1.All requirements included in this application correspond to the requirements set forth in Chapters 11 and/or 14 of the Dane ge0 <br /> County Code of Ordinances. <br /> 2. By submitting this application, permittee and landowner permit Dane County staff to enter project property for inspection Inwor b o <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)l. <br /> Applicant Signature: j..6 0 iii(AN.LA,CAAA Date: 05/04/16 <br /> If the person submitting the 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 to: <br /> Water Resource Engineering Division, 5201 Fen Oak Drive, Room 208, Madison, WI 53718 <br />