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Dane County For Office Use Only—Revised 01.03.2017 <br /> Erosion Control Permit Permit Number <br /> Application Application Received By: Date: <br /> (Application must be made in person. Application Approved By: Date: <br /> Incomplete applications will not be accepted) <br /> Associated Permits: <br /> Project Name: ---'V'S0'V 1-4 0'V\e- Applicant Information(Individual making in-person application) <br /> Landowner Name(s): f e* �" �� •vim LYSor∎ Applicant Name: D'e gv.oevs. <br /> Landowner Address: aDs.,63 awKYY1/40■3 JR( <br /> Applicant Address: lC�O � g ) <br /> w <br /> E Q.Asut i, , 5353 <br /> Landowner Phone: ((o06) J ` a J Applicant Phone: ) 75(( -113a Landowner E-mail: L Ve l!SO C- e_u3 4 0-`&4\00.CckM Applicant E-mail: 1re'e' 4 1 @-31ma t l- <br /> Name and company of engineer/consultant who prepared the plans: \kt Eu.Otyc • <br /> Type of Permit: Erosion Control Shoreland Erosion Control <br /> (check only one) J.' (EC) " (SE) <br /> l <br /> Municipality: . ?v.. J rK Section:aa Quarte Parcel#: <br /> a 511 -243 1 C-0 <br /> - <br /> Fee Calculation(all projects must include disturbed area and new impervious area) <br /> Total Disturbed Area ft2x$0.006/ft2 =$ 0 • 0 0 <br /> Total New Impervious Area ft2 <br /> (includes gravel) <br /> Total Redevelopment Impervious Area ft2 <br /> (includes gravel) <br /> Base Fee:Erosion Control(EC) $200 OR Shoreland Erosion Control(SE)$400 Base Fee=$ <br /> ❑Check box to apply$200 base fee for Shoreland Erosion Control <br /> (SE)projects meeting criteria in s. 11.05(2)(c) Total Fee=$ 0 . 00 <br /> Notes: <br /> 1.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 /> 2.By submitting this application,permittee and landowner permit Dane County staff to enter project property for inspection and/or <br /> curative action(s. 11.05(5)(a)3 or 14.49(4)(c)). <br /> 3.Late filing fee: The permit fee shall be doubled where work has begun before a permit has been obtained(s. 11.50(7)or <br /> I4.55(2)(b)). <br /> Applicant Signature: Date: <br /> If the person submitting the application is not the landowner,a notarized statement authorizing the applicant to act as the <br /> landowner's agent must be attached. <br /> This application must be submitted in person (M-F, 8 A.M. -4 P.M.) <br /> with two copies of all permit materials &fees to: <br /> Water Resource Engineering Division, 5201 Fen Oak Drive, Room 208, Madison, WI 53718 <br />