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lane County <br /> LCD office use only <br /> Erosion Control Permit Number: c'j7 9#7 g r0 a)) <br /> Simplified Checklist Application Date. 8 ,j - pg <br /> (Incomplete applications will not be accepted) <br /> This form may only be used for the following projects*: <br /> 1. Land disturbing activities administered under the Dane County erosion control ordinance whenever all three of the following <br /> conditions exist: <br /> a. The land disturbance is not more than 20,000 square feet in area;AND <br /> b. The land disturbance is not adjacent to and does not ultimately drain into any sensitive areas nearby,some examples being <br /> streams,lakes,or wetlands;AND <br /> c. The slope throughout the land disturbance is not more than 6%(6ft.vertical rise to 100ft.horizontal run) <br /> 2. Shoreland Erosion Control(SE)projects with P.E.waiver under DCCO 11.05(2)(b) <br /> *NOTE:A Regular Checklist Erosion Control plan is required if the above conditions are not met. Refer to Section 14.49 Dane County Ordinance <br /> Project Name: ROC.ic Potr:k Applicant Information(Individual making in-person application) <br /> Landowner Name(s): C 1'r,` s '/Qrny i&vtC.'K Applicant Name: r, <br /> Landowner Address: 53 I S4 i 3/ 6-74 Applicant Address: <br /> EnteSce LOT- 5 :Cy <br /> Landowner Phone: ��) &Pit V5-‘‘ Applicant Phone: <br /> Landowner E-mail: C rvt c.k T/✓ -, bar Applicant E-mail: <br /> Type of Permit: Erosion Control Only Shoreland Erosion Control Only <br /> (check only one) (EC) - (SE). <br /> Municipality: 721/4141 4j kk,e1 Section:,-9 /a + <br /> '� ; of the /, Parcel#: 05 1 de 13 <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 '7 ft2x$0.0040/ft2=$ <br /> Total New Impervious <br /> (includes graven <br /> Cott, <br /> Base Fee:Erosion Control-EC($200), Base Fee=$ �� <br /> OR Shoreland Erosion Control(SE)projects with P.E.waiver under DCCO 111.05(2)(b)($50) " <br /> Total Fee=$ CI <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: "Y Date: 071./5 6 <br /> If the person applying(submitting the application in person,at the counter)is not the landowner,a notarized statement <br /> authorizing the applicant to act as the landowner's agent must be attached <br /> Permit Reviewed and Issued by:—.4 ___701.-"2/%7---'41° Date: //,idast. <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 Rev.1/4/07 <br />