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• Dane County For Office Use Only—Revised 03.21.2016 <br /> Erosion Control Permit Permit Number + <br /> Simplified Application <br /> Received &Approved By: Date: ti/( <br /> (Application must be made in.person. 0�f <br /> Incomplete applications will not be accented.) <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:Tom Buglass House Applicant Information (Individual making in-person application) <br /> Landowner Name(s):Tom Bug l a s s Applicant Name:Tom B ugl a s <br /> • Landowner Address: 5075 Lincoln Rd ApplicantAddress: 5O75 Lincoln Rd <br /> Oregon, WI 53575 Oregon, WI 53575 <br /> Landowner Phone: ( 608 ) 320-8074 Applicant Phone: ( 608 ) 320-8074 <br /> Landowner E-mail:NA Applicant E-mail:NA <br /> Type of Permit: ✓ Erosion Control (EC) .Shoreland Erosion Control (SE) <br /> (check only one) <br /> Municipality:Town of Oregon J":Section ' 14 Quarter NE;- Parcel Number: 0509-141-8570-0 <br /> Fee Calculation <br /> Total Disturbed Area............................................ •5 r.0:0::0, ft <br /> Total New Impervious........... 2, 6 0 0 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. 11.05(5)(a)3 or 14.49(4)(c)). <br /> 3. Late filing fee: The permit fee shall be doubled where work has begun before a permit has been obtained (s. 11.50(7)or <br /> 14.55(21(b11. <br /> Applicant Signature! Date: >/ .Iite / le <br /> If the person submitting the application is not the la (owner, a notarized statement authorizing the applicant o 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 />