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Dane County For Office Use Only-Revised 01.13.2016 <br /> Erosion Control Permit Permit Number: <br /> Application Application Received By: Date; <br /> (Application must be made in person. Application Approved By: Date: <br /> Incomplete applications will not be accepted.) <br /> Associated Permits: <br /> Project Name:William Point Shoreline Repair Applicant Information(Individual making in-person application) <br /> Landowner Name(s): Kurt Dickey, Lois Harr Applicant Name:Ultimate Excavating <br /> Landowner Address: 2217, 2 2 2 9 Wiliam Point Applicant Address:W 7 8 4 5 Hwy 106 <br /> Stoughton WI Fort Atkinson wi 53538 <br /> Landowner Phone: (815) 978-5876 Applicant Phone: (920) 650-1135 <br /> Landowner E-mail: kdickey@dickey staffing.corn Applicant E-mail:mglockz @aol . COm <br /> Name and company of engineer/consultant who prepared the plans: Ul t imie Excavating <br /> Type of Permit: 1-71 Erosion Control Shoreland Erosion Control <br /> (check only one) (EC) (SE) <br /> Municipality:Town of Pleasant Springs Section: Quarter: Parcel#: <br /> Fee Calculation(all projects must include disturbed area and new impervious area) <br /> Total Disturbed Area 2 , 000 ft2 x$0.005/ft2 =$ 10 . 0 0 <br /> Total New Impervious Area 0 ft2 <br /> (includes gravel) <br /> Total Redevelopment Impervious Area 0 ft2 <br /> (includes gravel) <br /> Base Fee:Erosion Control(EC) $200 OR Shoreland Erosion Control(SE)$400 Base Fee=$ 200 . 00 <br /> ❑Check box to apply$200 base fee for Shoreland Erosion Control <br /> (SE)projects meeting criteria in s.11.05(2)(c) Total Fee=$ 210 . 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 1 ) <br /> licant Si : [flL/L('1 ��� Date:S 4)-�6 <br /> PP Signature:. <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 &fees to: <br /> Water Resource Engineering Division, 5201 Fen Oak Drive, Room 208, Madison, WI 53718 <br />