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Dane For Offices O u n ty Use Only—Revised 01.13.2016 <br /> Erosion Permit Number Control Permi — <br /> Simplifi d Application <br /> (Application mu Received&Approv: t be made in person. " By: Date: <br /> Incomplete apply ations will not be accented.) <br /> This form ma owing projects: , only be used for the fo <br /> 1. Land disturb' of DCCO s. 14.50(2) ng activities meeting the criteri. <br /> 2. Land disturb' oreland Zone meeting the criteria of DC ng activities occurring in the S . 0 s. 11.05(2)(b)or(d) <br /> Please see Da es for the complete list of qualify e County Code of Ordinan q criteria. <br /> Project Name:S Applicant Information ed (Individual making in-person application) <br /> Landowner Nam: _ Applicant Name:An (s):Andy Lange •y Lange <br /> Landowner Addl.:) F Applicant Address:3 s:3690 County Ri • 90 County Rd F <br /> 53517 B Blue Mounds, WI lue Mounds, WI 53517 <br /> Landowner Phon Applicant Phone: ( (608) 636-3423 0 8) 636-3423 <br /> Landowner E-ma ' 1 . corn ApplicantE-mail:1- I: langeandyj @qma 1 geandyj @gmail . com <br /> Type of Permit: I I Shoreland Erosi. WI Erosion Control(EC) Control(SE) <br /> (check only one) <br /> Municipality:T• %ection: 29 Quarter: NE I/4 Parc: wn of Vermont CI I Number: 0706-291-8010-0 <br /> Fee Calculation <br /> Total Disturbed • 18, 000 rea ft L <br /> Total New!mine 5, <br /> 750 5 0 ious <br /> (includes gravel) Base Fee=$ 10 0 . 0 0 <br /> Total Fee=$ 10 0 . 0 0 <br /> Notes: <br /> 1. All requiremen .espond to the requirements set forth in 4 ;included in this application c• hapters 11 and/or 14 of the Dane <br /> County Code o Ordinances. <br /> 2.By submitting downer permit Dane County staff to ent: its application, permittee and la r project property for inspection and/or <br /> curative action s. 11.05(5)(a)3 or 14.49(4)(c)). x_ <br /> 3. Late filing fee: where work has begun before a permit ' he permit fee shall be doubled as been obtained (s. 11.50(7)or <br /> 14.5512)(b)). <br /> Applicant Sign �� // ture: �,� � c.° Date: 3 <br /> If the person s 4 the landowner,a notarized stateme ibmitting the application is nctilt authorizing the applicant to act as the <br /> landowner's a ent must be attached. <br /> be submitted in person (M-F This application must , 8 A.M. -4 P.M.) <br /> copies of all permit material with two v-; to: <br /> Water Resou ion, 5201 Fen Oak Drive, - ce Engineering Divi- oom 208, Madison, WI 53718 <br /> 3= <br />