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0.....EC n 131 KLS 0911z12ao (o <br /> F©2_ 3.6.--8 S S-n(ei c <br /> ' Dane County Erosion Control and Stormwater Management <br /> Application <br /> (Incomplete applications will not be accepted) <br /> Permit#: SE 7-00(0 - <br /> Date: 9/12/06 <br /> Project Name: Dale Scholr Property -- Pac-e— .'A' Applicant(Individual making in-person application): <br /> Landowner Name(s): Dale Scholl Applicant Name: <br /> Applicant Address: 0 A <br /> A <br /> Landowner Address: 8908 Domini Road PP 2 2-NS Horeb, WI 53572 <br /> MOM z�NlN lb . <br /> Landowner Phone:( ) Applicant Phone: <br /> Name and Company of Engineer/Consultant who designed the plans,if applicable: Quam Engineering, LLC <br /> rosion Control afnd Stlnntvater Management Stormwater Management Only <br /> Type of Permit: Erosipn Control Only D . (SM) <br /> (check only one) <br /> (EC) `r (ES) <br /> 0 Redevelopment 7 Shorelai d 1✓rosipn Coritrol Onl; D Shoreland Erosion Control and <br /> P f (or ''` ° Stormwater Management(SS) <br /> (RD) ($E)(;orderly Filling&�rading) i i ',, <br /> Municipality:Town of Cross Plains t. Seetlon 33 r' ���I4 U4t NE,SW Parcel#: 0707-333-8000 4 <br /> Fee Calculation(all projects must include distur) d area ar d newimpgr iptis area,le n toot included in fee): <br /> Total Disturbed Area(square feet): <br /> : 3,000 x 0.004 $/sq.ft. _ $ 92.00 <br /> Total New Impervious Area(includes gravel)(square feet)f ''i ' <br /> 19,680 x 0.005 $/sq.ft. = $ 0.00 <br /> Total Redevelopment Impervious Area(includes gravel)(square feet): {. 0 x 0.0025 $/sq.ft. = $ 0.00 <br /> Base Fee=EC,ES,SM,or RD($200);SE or SS with structure ($400),SE or SS without structure Base Fee = $ <br /> 400.00 <br /> ($200);or SE projects with P.E.waiver under 11.05(2)(b)($50) Total Permit Fee = $ 492.00 <br /> Notes: <br /> 1. Be sure to indicate the limits and size(sq.ft.)of all disturbed and impervious area on your plan. <br /> 2. All requirements on this checklist correspond to the requirements set forth in Chapter 11 and 14 of the Dane County Code of Ordinances. <br /> 3. By submitting this application,permittee and landowner permit the Dane County Zoning Administrator to enter project property for inspection <br /> or curative action(s. 14.49(4)c or 11.05(5)(a)3 DC ode of Ordinances). (� �j <br /> Landowner or Applicant Signature: IZO.Acb_____ I Date: / !/ICJ <br /> (If applicant is not the landowner,attach a notarized statem thorizing app scant to act as landowner's agent) <br /> Zoning Reviewed by: Date: <br /> Land Conservation Reviewed by: Date: <br /> Permit Issued by: Date: <br /> THIS APPLICATION MUST BE SUBMITTED IN PERSON, WITH TWO COPIES OF ALL <br /> PERMIT MATERIALS TO DANE COUNTY ZONING, M-F, 7:45 A.M.- 4:00 P.M. <br /> Revised 12/06/05 <br /> F- DATE QC _ CZ- - 2c0 a N0,14 2 4 083 <br /> 0. RECEIVED FROM DA E_ s c-4o L'1_, $4/Z 92 <br /> F k c. I- CA ,SD IVE,0 13 l 6.7 (^ I W O ' 1.-5 c9 1 of„---DOLLARS <br /> U <br /> � H rV HtNI ' <br /> O FOR < Yom. L40.,1..7 0 tvrZ_O S I.c) r...► co 4--5`T-12_,d L. 21f.t2-0-( t r <br /> 'P'-'r x'�+ Coq-�0 4:7 <br /> W _ 4 oa CASH I zi, `a— •FROM TO <br /> PAYMENT 6' –iei @CHECK <br /> ceBAL. DUE 41 9� v� BY /(t/7i L 5CiGt c.�1 <br /> 11��� a x.2701 • <br />