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Dane County <br /> Erosion Control & Stormwater <br /> Management Permit Application <br /> (Incomplete applications will not be accepted) <br /> Project Name: 'Clee '/J 1 ),to u'..-• %Pi-NM Applicant Information(Individual making in-person application) <br /> Landowner Name(s): VA cp' l�eln-u, Applicant Name: 01(/V Mop-I-6,1.43A/Le <br /> Landowner Address: DJ 14I 119 C'i ru I c(A) Applicant Address: 18 , 141.)0S0).,) S-7' <br /> /�P> . ray SAZ/ :,.l- 53S7c // NA20M.-NtetwL 53Sloa <br /> Landowner Phone: tOOL 44-c '0 4Ze Applicant Phone: L[,J13'7` S' 4 g..+0 <br /> Landowner E-mail:Ilia} PUtJ1 r1V.49C,ONSTPUN-TS +tOAA Applicant E-mail: MOM•-1-61-' & C7ufl L-f 1 <br /> Name and company of engineer/consultant who prepared the plans: f3(Ai AltifOi‘(214.NO , -(7tvT <br /> Type of Permit: Erosion Control Only n Erosion Control&Stormwater Management Stormwater Management Only <br /> (check only one) �(EC) (ES) - ,-: (SM) <br /> Redevelopment O ShoRean ErosiopCbritrolOnly " Shoreland Erosion Control& <br /> (RD) SE , <br /> Stormwater Management(SS) <br /> Municipality: Q(Ai(J OF MA2OM,4■ I‘, 'Secfion 1'7 SSW /4 of_th444, %. Parcel#:031-.0 8640-1 ?.4•t)ZOD-0 <br /> Fee Calculation(all projects must include distiirbe4f ar`e~ar id rieW,mpelvi i` ,even'•.it rigt subject to fee as noted by brackets) <br /> 4 <br /> Total Disturbed Area...EEC,ES,RD,SE,SS].:. ......... ...{; r st 1bsO .' ftZx$0.0040/ft2 =$ LOU <br /> Total New Impervious...[ES,SM,RD,SS]..... .i Witei 0d <br /> .... T,�� ft2 $0.00501ftZ=$ , <br /> (includes gravel) <br /> Total Redevelopment Impervious...[RD].... h..t <br /> t.F. � � <br /> 14 s ft2x$0.0025/ft2 =$ <br /> (includes gravel) _ <br /> p� <br /> Base Fee: EC, ES, SM, or RD($200); SE or SS with'new':or replacemant-structure($400); Base Fee=$ 2 Ob <br /> SE or SS without new or replacement structure($200);or SE perrn itwith P.E.waiver under eo <br /> DCCO 11.05(2)(b)($50)[subtract PRL fee($50)if application includes PRL and receipt] Total Fee=$� -- <br /> eafaO- <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. • ••,-)c or 11.05(5)(a)3 DC Code of Ordinances) <br /> ar <br /> Applicant Signature: 1 h, Date: (.10'ZS-0 8 <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 Received by: 744- .7,-- Date: (Ohl 7/0 <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 />