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Dane County LCD office use only <br /> Erosion Control Permit Permit Number: <br /> Simplified Application Date: <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) <br /> Please see Dane County Code of Ordinances for the complete list of qua! ing criteria. <br /> Project Name: 3 i Z$ \i A Et 1 A 1 l .rat L-- Applicant Information Individual making in-person application) <br /> ! <br /> Landowner Name(s): U$1 14441/iiAt tO"Applicant Name: y��'v'1fM N`J'r Iden. INC_ <br /> Landowner Address: 312f3 -ge-1-04-- i • Applicant Address: /Z V I a t/II a444s S <br /> -1T •1 bo KI -3�703�/ <br /> Landowner Phone: ,r7 ll'//,'500d ��# S(4 Applicant Phone: 2 !• I/`7 5 /— t <br /> Landowner E-mail: 141144'1 2 5f601• cowl Applicant E-mail:jSV -I"l �' �1at te..A.4u l GdP") <br /> Type of Permit: 0 Erosion Control(EC) ErShoreland Erosion Control(SE) <br /> (check only one) + <br /> Municipality: Tot�lr�l OF bi1Mr4 Section: 0 55 Quarter. tk Parcel Number. 0101 DO`-;1147.0(o0 <br /> Fee Calculation • <br /> Total Disturbed Area................................................................... ... sq.ft. <br /> Total New Impervious......................................................... .9. sq.ft. <br /> (includes gravel) Base Fee=$ 100.00 <br /> Total Fee=$ 100.00 <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. 14.4• - c or 11.05(5)(a DC Code of Ordinances) <br /> 4 Oh - d D` <br /> � <br /> Applicant Signature: dal/V Date: <br /> ` <br /> If the person applyin••matting the application in-person,at the counter)is not the landowner,a notarized statement <br /> authorizing the applic• to act as the landowner's agent must be attached <br /> Permit Reviewed and Issued 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 /> Dane County Land Conservation, 1 Fen Oak Ct, Room 208, Madison, WI <br /> Rev.01/26/09 <br /> a •d OEStr .17LZ 809 ou i 2u t Jaau t 2u3 Aer i eRoN e80 :60 60 SO 2n171 <br />