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Dane County LCD office use only-Revised 1.13.09 <br /> Erosion Control & Stormwater Permit Number: S ,q -a, <br /> Management Permit Application Date: s- 7-01 <br /> (Incomplete applications will not be accepted) <br /> Project Name: 336 Lake Shore Drive Applicant Information(Individual making in-person application) <br /> Landowner Name(s): Al Stevens Applicant Name: <br /> Landowner Address: 311 Dacy Street Applicant Address: <br /> Woodstock, IL 60098 <br /> Landowner Phone: go-, �•�%9 -O'` Applicant Phone: <br /> Landowner E-mail:.5h,dOZ 6( 5E3( 4.60.6it•A115— Applicant E-mail: <br /> Name and company of engineer/consultant who prepared the plans: Quam Engineering, LLC <br /> Type of Permit: r---1 Erosion Control Only 1-1 Stormwater Management Only n Erosion Control&Stormwater <br /> (check only one) (EC) (SM) Management(ES) <br /> r� Shoreland Erosion Control Only n Shoreland Erosion Control& <br /> lr 1 (SE) Stormwater Management(SS) <br /> Municipality: Town of Albion Sectior25 Quarter: SE Parcel#: 0512-254-2001-4 <br /> Fee Calculation(all projects must include disturbed area and new impervious,even if not subject to fee as noted by brackets) <br /> Total Disturbed Area...[EC,ES,SE,SS] 5,000 <br /> ft2x$0.005/ft2 =$ 25.00 <br /> Total New Impervious...[ES,SM,SS] ft2 x$0.010/ft2 =$ <br /> (includes gravel) <br /> Total Redevelopment Impervious...[ES,SM,SS) 600 ft2x$0.005/ft2 =$ 0.00 <br /> (includes gravel) <br /> Base Fee:$200-EC or SE meeting criteria in Ch. 11.05(2)(c);$400-ES, SM, SE,or SS Base Fee=$ 400.00 <br /> Total Fee=$ 425.00 <br /> Notes: <br /> 1.Be sure to clearly indicate the extent(limits)and size(ft2)of all disturbed and impervious areas on your plan <br /> 2.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 /> 3.By submitting this application, permittee and landowner permit Dane County staff to enter project property for inspection and/or <br /> curative action(s. 14.49 4)c or 11.05(5)(a)3 DC Code of Ordinances) <br /> i <br /> Applicant Signature: �f ..h • � ��. Date: 5- !'0? <br /> If the person applying(submitting t ap•li '•n in-person,at the counter)is not the landowner, a notarized statement <br /> authorizing the applicant t• 'ct a • I. d• ner's agent must be attached <br /> Permit Received by: Date: J' <br /> Permit Reviewed b . 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 />