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c`, C) I6 <br /> Dane County For Office Use Only-Revised 03.21.2016 <br /> Erosion Control Permit Permit Number 'EC- `2-°\ 6 --00 <br /> Simplified Application <br /> (Application must be made in person. Received&Approved By: )AS Date: 37as/[ <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: TO.c l\Ot' f\e c Ekneil S1.4 Applicant Information(Individual making in-person application) <br /> Landowner Name(s): S1vetc1c -7 0-0 A Applicant Name: S keta o r\ TooC41ot1 - <br /> Landowner Address: 5a.3 5 Lo cuSt Grove �oo,ck Applicant Address: 5./.5 5 Locust- Goa &OA <br /> c)�Tq©c\ WI- 5357 5 4p�ven W:L 5357 5 <br /> Landowner Phone: 608 935 511 b Applicant Phone: 608 l/$3 J 5116 <br /> Landowner E-mail: s k to.c k n 5 3E Ckokr-Fecr plicant E-mail: S gCh01\534.�o.r for .R��� <br /> Type of Permit: ® Erosion Control(EC) Shoreland Erosion Control(SE) <br /> (check only one) <br /> Municipality: 070 4 Y\ Section: cx Quarter: 1\1d) Parcel Number: 05 OS- A 3 cs—$540--{ <br /> Fee Calculation <br /> Total Disturbed Area Q 00 0 ft2 <br /> Total New Impervious G. 510 ft2 <br /> (includes gravel) Base Fee=$ 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. 11.05(5)(a)3 or 14.49(4)(c)). <br /> 3. Late filing fee: The p-.it fee shal be doubled i-re wort has begun before a permit has been obtained(s. 11.50(7)or <br /> 14.55(2)(b)l. <br /> Applicant Signature•_�m7t� I1A])�\ �; •!� b Date: 3- 5-010 <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 />