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Dane County p . tt �� � � g <br /> Erosion Control & Stormwater c- $m-71.0k t.--t P, i Att �AL.p 0 } t <br /> Management Permit Application . h } M _ r d ', i } , , 1 <br /> (Incomplete applications will not be accepted) >s . r <br /> ,.3sa,.c �'LC,.. ,�e-ca.a._ w... S�.r J.._�. ?:�', r xW.,- _ <br /> Project Name: Alden Bosben Proposed Home Applicant Information(Individual making in-person application) <br /> Landowner Name(s): Alden Bosben Applicant Name:Alden Bosben <br /> Landowner Address: 1516 Main St Applicant Address: 1516 Main St <br /> Cross Plains, WI 53528 Cross Plains, WI 53528 <br /> Landowner Phone: 608-235-2545 Applicant Phone: 608-235-2545 <br /> Landowner E-mail: Applicant E-mail: <br /> Name and company of engineer/consultant who prepared the plans: Jonathan Lefers PE, Montgomery Associates <br /> Type of Permit: ni Erosion Control Only Stormwater Management Only Erosion Control&Stormwater <br /> (check only one) (EC) (SM) Management(ES) <br /> 0 <br /> Shoreland Erosion Control Only -ShQrejarid Erosion Control& <br /> (SE) �•Stormwater Management(SS) <br /> Municipality: iN SUr4 PQ-Ai Ate- ' LSedtit n.221., Quarter°.SW Parcel#: oS 1 r a 9 3—8503 "O <br /> Fee Calculation(all projects must include disturbedare "aitrd new"4mpervtpus even.if not subject to fee as noted by brackets) <br /> Total Disturbed Area...[EC,ES,SE,SS] ;...,.....7......:....,.. -2.8,070 ft2 x$0.005/ft2 =$ 115.35 <br /> Total New Impervious...[ES,SM,SS] ' ,. ft2 x$0.010/ft2 =$ 0.00 <br /> (includes gravel) <br /> Total Redevelopment Impervious...[ES,SM SS] .. ft2 x$0.005/ft2 =$ 0.00 <br /> (includes gravel) <br /> Base Fee:$200-EC or SE meeting criteria in Ch. 1 1.05(2)(c),$40.0 ;"ES,"SM,SE, or SS Base Fee=$ 400.00 <br /> Total Fee=$ 515.35 <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 /> Applicant Signature: do-e4.••■- V 6.41,u241_ Date: 0 447.2 7 --O °r <br /> If the person applying(submitting the a ation in-person, at the counter)is not the landowner,a notarized statement <br /> authorizing the applicant to t as t an er's gent must be attached -7 <br /> Permit Received by: Date: Q�l'�/ 01 <br /> Permit Reviewed 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 />