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Dane County For Office Use Only—Revised 03.21.2016 in <br /> Erosion Control Permit Permit Number , 7,016 <br /> Simplified Application T <br /> eceived&Approved By: J Al A Date: <br /> < <br /> (Application must be made in person. <br /> 1 � <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:Hanson Aq Bui ldinq Applicant Information (Individual making in-person application) <br /> Landowner Name(s): Chris Hanson Applicant Name: same <br /> Landowner Address: 2 410 Hwy 92 Applicant Address: <br /> Mount Horeb <br /> Landowner Phone: (6 0 8) 8 3 2-4 415 Applicant Phone: <br /> Landowner E-mail: Cahanson 5 1@msn. corn - Applicant E-mail: <br /> Type of Permit: NI Erosion Control(EC) n Shoreland Erosion Control(SE) <br /> (check only one) <br /> h, <br /> Municipality: Town of Springdale Section 18 f'Quarter NE Parcel Number 0 6 0 7-184-8 0 0 0-7 <br /> 4 <br /> Fee Calculation <br /> Total Disturbed Area 19 , 99}9 ft` <br /> Total New Impervious 19 , 9 0 0 ft1 <br /> (includes gravel) ; Base Fee=$ 10 0 . 0 0 <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 permit fee shall be doubled where ork has begun before a permit has been btained(s. 11.50(7)or <br /> 14.55(2)(b)). �/ ^ �Q A �1, ff��fr' L Appl ant ignatu : / I / Or l /'X/z 1 / <br /> If the person submitting the ap lication is not the landowner,a notarized statement authorizing the applicant to act as the <br /> landowner's agent must be attached. 5 /(10 — /0////6 <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 />