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Dane County i<< , , h <br /> t <br /> Erosion Control & Stormwater <br /> h }?� y 74 <br /> Management Permit Application ii IP rT <br /> (Incomplete applications will not be accepted) _. 'ik-13r.. - L .--_.._ _._.-,L, <br /> Project Name:Baliweg Property Applicant Information(Individual making in-person application) <br /> Landowner Name(s):Joel Ballweg Applicant Name:Joel Baliweg <br /> Landowner Address:6996 Dunlap Hollow Rd. Applicant Address:6996 Dunlap Hollow Rd. <br /> Landowner Phone:608-220-9866 Applicant Phone:608-220-9866 <br /> Landowner E-mail:Joel-nancyballwegaearthlink.net Applicant E-mail:joel-nancyballweg @earthlink.net <br /> Name and company of engineer/consultant who prepared the plans: Ramaker&Associates, Inc. (K. Bohnsack, P.E.) <br /> Type of Permit: Erosion Control Only Erosion Control&Stormwater Management Stormwater Management Only <br /> (check only one) (EC) (ES) (SM) <br /> • Redevelopment Shofeland.ErosionControl,Only Shoreland Erosion Control& <br /> - (RD) Q°(SE) Stormwater Management(SS) <br /> Municipality:Town of Roxbury st.ptiot,:-20 las.oo 8W;y Parcel#: 050/0907-203-8710-8 <br /> Fee Calculation(all projects must Include Ofeittirbed*Sted.nekv;impervtojus,even ft nefisubject to fee as noted by brackets) <br /> Total Disturbed Area...[EC,ES,RD,SE,SS] ............. ........... .x 4540 ` ! ft2x$0.0040M =$ 14.16 <br /> Total New Impervious...IES,SM,RD,SS] 4.708 _ ft2x$0.0050/ft2=$ 8:54- <br /> (mdudes gravel) <br /> Total Redevelopment Impervious...[RD] ........: ......... ......... ......_0 • ft2x$0.0025/ft2=$ 0.00 <br /> (Includes grate <br /> Base Fee:EC,ES,SM,or RD($200);SE or SS with new or.repiacement-structure($400); Base Fee=$ 400.00 <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($50)if application indudes PRL and receipt] Total Fee=$ <br /> 'f11,i c. .1� <br /> 1.Be sure to clearly indicate the extent(limits)and size(ft)of all disturbed and impervious areas on your plan �W' <br /> Notes: <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( •r 1 15(5 DC Code of Ordinances) <br /> Applicant Signature:OA&_ II'4 j/� Date: 61,02 7/08 <br /> if the person app g(submitting the appl•01,1rt In-person,at the counter)Is not the landowner,a notarized statement <br /> authorizing the applicant to act as the Ian.• is agent must be attached <br /> Permit Received by: v Date: t, /30/C38 <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 />