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• <br /> . Dane County LCD office use only �t <br /> Erosion Control & Stormwater PenmtNumber <br /> c . <br /> Management Permit Application Dato -1O =08 <br /> (Incomplete applications will not be accepted) <br /> Project Name: U`I H Applicant Information(Individual making in-person application) <br /> Landowner Name(s): ?;(,[{" s CAtU 1yrJ !UJ vrJ `Applicant Name: j G \A)I11 Frt. <br /> Landowner Address: 17O 3 COUviTy V?o 13e Applicant Address: 170 3 C <br /> Carr G G R c11P, \nI De('rF:t 11n IJJj S J 3} { <br /> Landowner Phone:(10_6 p 7 6 4- C/1q 7 Applicant Phone: -,'' •) 'I- S 76 7 <br /> Landowner E-mail r\i l�lv�l pm) e,/'�A.,1_[? a . (a v. Applicant E-mail: 2uvy/v)hr\,] (� /1I Pr',Lia u <br /> // �j J <br /> Name and company of engineer/consultant who prepared the plans: <br /> Type of Permit: Erosion Control Only Erosion Control&Stormwater Management Stormwater Management Only <br /> (check only one) L (EC) I (ES) (SM) <br /> Redevelopment I I,Shoreland Erosion Control Only I Shoreland Erosion Control& <br /> (RD) (SE) Stormwater Management(SS) <br /> Municipality: rerrrA6F t a(I o v E Section: 13 1 ,ofthet4E %, Parcel#: (07u —( r 1 3 t - qt SO —o <br /> Fee Calculation(all projects must include disturbed area and newimpervious,even if not subject to fee as noted by brackets) <br /> Total Disturbed Area...[EC,ES,RD,SE,SS] q8 ft2 x$0.0040/ft2 =$ 3, &O <br /> Total New Impervious...[ES,SM,RD,SS] ft2x$0.0050/ft2 =$ <br /> (includes gravel) <br /> Total Redevelopment Impervious...[RD] . ft2x$0.0025/ft2 =$ <br /> (includes gravel) <br /> Base Fee: EC, ES, SM, or RD($200); SE or SS with new or replacement structure($400); Base Fee =$ doe)•0O <br /> SE or SS without new or replacement structure($200); or SE permit with P.E.waiver under <br /> DCCO 11.05(2)(b)($50)[subtract PRL fee($50)if application includes PRL and receipt] Total Fee=$ 023-2 6° <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 05(5) a)3 DC Code of Ordinances) <br /> Applicant Signature: Date: lalfD/D 9 <br /> If the person applying(submitt he appli do in-person,at the counter)is not the landowner,a notarized statement <br /> authorizing the applicant to t as the I do is agent must be attached <br /> Permit Received by: Date: /O/;p l8 <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 />