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Dane County Zoning office use only <br /> Non-Metallic Mining Reclamation Permit.# <br /> liw Permit Application Date <br /> 6C1 QTR i LLC Ta-t).-57-' <br /> CPu <br /> Landowner Agent: �y�t (--7/ i r r Y ) k iii <br /> Address:T. GX 44284 1-7 � <br /> 0444 Address:/' 3 L„2:34.3-6, 7s. i,,llL 0.56.4,a <br /> yt az Ise),1 1/u i 13244 kLy,J, w I l,\/ LE.51-1-A, Lvl S- i 7 <br /> Phone: n <br /> Fj37 / *_ 1(2,8 Li ? a-1 Phone: f 2_ 2_) 5-Z' - !7 cO <br /> E-mail: E-mail: C.A./e Ail�-et-e �Q - nl9_c- /cx Jo I r.) , C to <br /> J <br /> Address of site: /6-7 --- /14'47 3 O k(_y,-.1' /..„}i <br /> J <br /> pp (may need to be assigned) <br /> Township: Di2-6 C1 0'Ni <br /> Parcel#: <br /> O SO 1 3 4. — ( S S4 l 0 - Parcel#: 05-C)?C)?3 '-- l /SD ) a <br /> - - ZRb ,( 'U <br /> Parcel#: Parcel#: S / <br /> , ` <br /> l� — `-t' 8 ( Ot O <br /> Parcel#: I � � I� Parcel#: <br /> \A <br /> Parcel#: 1 1� fl o k Parcel#: 6 Db 2_o <br /> / /q3 <br /> Type of aggregate: �r�rt� ¶t ) `2 AA)C.-L___ Total site acreage: <br /> /i / 3t� <br /> Plan review fees: <br /> (Less than one acre:NO FEE, 1 to 25 acres:$875.00, 25 to 50 acres:$1,100.00, More than 50 acres:$1,300.00) <br /> Non-conforming: Yes or No Conditional use permit#: <br /> Effective Date <br /> Expiration Date:, <br /> - Erosion control/Stormwater permit#: Expiration Date: <br /> I hereby request on behalf of the applicant a non-metallic mining permit. I certify,as adult'authorized representative or agent that the <br /> operator listed above will comply with the statewide non-metallic mining reclamation standards established in ss.NR 135.05 through <br /> NR 135.15,Wis.Adm.Code. The applicant agrees to provide to Dane County an annual fee as established by county ordinance and <br /> site access for county official ec•. r to evaluate this application and ensure compliance with a permit. Also,financial assurance <br /> standards as established i• Ch.1 I■ Dane Cou " Code of Ordinances. <br /> -, `6 <br /> Applicant signature: <br /> Date: <br /> If the person applying(submitting the application i person,at the counter)is not the landowner,a notarized statement <br /> authorizing the applicant to act as the landowner's agent must be attached. • <br /> c, Permit received by: Date: <br /> Permit reviewed by: Date: <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 /> Wane Cnunty Zonina. 210 Martin Luther King Jr. Blvd. Room 116, Madison,WI <br />